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in  tfte  €itv  of  i^eto  gorfe 

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WORKS   BY 

W.  SOLTAU  FENWICK,  M.  D. 


Dyspepsia :  Its  Varieties  and  Treatment 

Cancer   and   Other    Tumours    of    the 
Stomach 

Ulcer  of  the  Stomach  and  Duodenum 

Disorders  of  Digestion  in  Infancy  and 
Childhood 

The  Dyspepsia  of  Phthisis 


WITH  THE  LATE  DR.  SAMUEL  FENWICK 

The  Student's  Guide  to  Medical  Diag- 
nosis Ninth  Edition 

Outlines  of  Medical  Treatment 

Fourth  Edition 


DYSPEPSIA 

ITS    VARIETIES    AND    TREATMENT 


BY 

W.  SOLTAU  FENWICK,  M.  D.  (Lond.) 

DOCTOR  OF  MEDICINE  OF  THE  UNIVERSITY  OF  STRASSBURG;  LATE  PHYSICIAN 
TO  THE  EVELINA  HOSPITAL  FOR  SICK  CHILDREN,   ETC. 


ILLUSTRATED 


PHILADELPHIA  AND  LONDON 

W.  B.  SAUNDERS  COMPANY 

1910 


Copyright,  191  o,  By  W.  B.  Saunders  Company. 


.1^ 


PRINTED     IN    AMERICA 


PREFACE. 


The  scheme  upon  which  the  present  work  is  based  was 
drawn  up  by  the  author  more  than  sixteen  years  ago.  Only 
a  few  chapters  had  been  written,  however,  before  it  became 
evident  that  the  subject  was  infinitely  more  complicated  than 
had  been  imagined,  and  the  manuscript  was  accordingly  put 
aside  until  sufi&cient  knowledge  had  been  gained  to  warrant  a 
fresh  attempt.  In  the  meanwhile  a  series  of  special  researches 
were  undertaken  upon  the  etiology  of  the  various  forms  of 
dyspepsia,  and  monographs  dealing  with  such  cognate  sub- 
jects as  Disorders  of  Digestion  in  Childhood,  Ulcer  of  the 
Stomach,  and  Cancer  of  the  Stomach  were  published. 

The  present  volume  is  the  outcome  of  the  clinical  experi- 
ence gained  by  the  personal  examination  and  treatment  of 
more  than  eighteen  thousand  persons  suffering  from  indiges- 
tion; but  since  the  data  thus  obtained  proved  too  unwieldy  for 
analysis,  the  statistical  enquiries  quoted  in  the  text  were  con- 
fined to  one  thousand  examples  of  the  complaint,  five  hundred 
of  which  were  examined  in  hospital  and  five  hundred  in  pri- 
vate practice.  These  were  taken  in  the  order  in  which  they 
came  under  observation  and  were  all  subjected  to  the  same 
methods  of  investigation,  so  that  the  results  probably  indicate 
with  a  fair  degree  of  accuracy  the  relative  frequency  of  the 
different  types  of  dyspepsia  in  general  and  special  practice, 
respectively. 

The  difficulties  which  beset  the  clinical  study  of  indigestion 
are  due  in  great  measure  to  the  almost  universal  disposition 
to  regard  the  condition  as  a  substantive  disease  dependent 
upon  a  primary  failure  of  the  gastric  functions,  whereas,  in  a 
large  proportion  of  the  cases,  the  symptoms  originate  entirely 

7 


8  PREFACE. 

in  the  intestines  and  ensue  from  a  derangement  of  the  liver, 
pancreas,  or  bowel.  Moreover,  a  disturbance  of  digestion  in 
the  stomach  itself  is  rarely  due  to  a  primary  disorder  of  that 
viscus,  but  is  usually  a  consequence  of  serious  disease  of 
another  and  perhaps  remotely  situated  organ  of  the  body.  The 
truth  of  this  apparent  paradox  will  be  appreciated  when  it  is 
remembered  that  the  majority  of  the  secretory,  motorial,  and 
inflammatory  affections  of  the  stomach  result  from  the  failure 
of  some  other  organ  to  execute  its  proper  functions. 

It  is  also  seldom  understood  that  chronic  indigestion  is 
never  due  to  the  perversion  of  a  single  physiological  process, 
and  that  the  digestive  apparatus  is  of  such  delicate  construction 
and  perfect  adjustment  that  the  slightest  disturbance  of  one 
of  its  parts  will  eventually  throw  the  entire  mechanism  out 
of  gear.  Thus,  a  continuous  secretion  of  gastric  juice,  secon- 
dary, perhaps,  to  disease  of  the  appendix,  will  in  the  course  of 
time  produce  inflammation  of  the  mucous  membrane  of  the 
stomach,  gastrectasis,  and  motor  insufficiency,  which  in  their 
turn  may  be  followed  by  functional  derangements  of  the  liver 
and  pancreas,  enteritis,  and  even  by  ulceration  of  the  duode- 
num. It  is  only  by  careful  investigation  of  each  individual 
case  that  the  initial  disorder  can  be  ascertained  and  a  clue  ob- 
tained to  the  numerous  and  diverse  conditions  which  so  often 
obscure  the  original  complaint. 

The  problems  of  dyspepsia  are  further  complicated  by  the 
imaginative  nomenclature  with  which  the  subject  has  been 
clothed  and  by  the  exaggerated  importance  accorded  to  phe- 
nomena of  a  secondary  and  purely  subsidiary  character.  The 
term  "dilatation  of  the  stomach"  appears  to  be  regarded  by 
the  medical  profession  not  only  as  an  invariable  accompani- 
ment of  indigestion,  but  as  an  actual  disease  of  the  stomach, 
which  through  the  medium  of  "fermentation"  and  "auto- 
intoxication" is  capable  of  producing  every  symptom  which  the 
human  mind  can  conceive.  Quite  apart,  however,  from  the 
fact  that  gastrectasis  can  rarely  be  diagnosed  by  the  methods 


PREFACE.  9 

commonly  employed  for  its  detection  and  that  it  is  usually 
confounded  with  gastroptosis,  those  who  worship  this  fetish  of 
their  imagination  never  comprehend  that  gastric  dilatation  is 
not  a  primary  condition,  but  is  merely  a  consequence  of  some 
long-standing  functional  or  organic  disease  of  the  viscus.  No 
true  clinician  would  dream  of  maintaining  that  dilatation  of 
the  heart  was  a  primary  disease  or  would  be  content  to  treat 
it  without  making  some  attempt  to  ascertain  its  cause;  yet 
how  few  ever  regard  dilatation  of  the  stomach  as  the  result  of 
a  definite  lesion  or  grasp  the  fact  that  gastrectasis  is  not  a 
disease,  but  merely  the  consequence  of  one.  The  existence  of 
gastric  dilatation  in  a  case  of  dyspepsia,  although  of  importance 
from  the  point  of  view  of  prognosis  and  treatment,  no  more 
explains  the  nature  of  the  indigestion  than  does  the  discovery 
of  a  dilated  heart  indicate  the  disease  from  which  it  has  arisen. 

In  the  first  chapter  a  short  scheme  is  offered  for  the  clinical 
differentiation  of  the  various  forms  of  dyspepsia.  This  was 
originally  drawn  up  for  the  benefit  of  those  medical  men  who 
attended  the  author's  demonstrations  upon  diseases  of  the 
stomach,  but  since  it  has  stood  the  test  of  time  and  appears 
to  have  been  of  some  use,  it  is  now  published  for  the  first  time. 

Its  sole  value  is  to  concentrate  attention  upon  such  clinical 
indications  as  serve  to  distinguish  one  form  of  the  complaint 
from  another  and  to  emphasize  the  importance  of  discriminat- 
ing between  disorders  of  function  as  opposed  to  mere  symptoms. 
It  makes  no  claim  to  exceptional  accuracy,  nor  can  it  be  use- 
fully employed  unless  the  student  possesses  a  good  general 
knowledge  of  the  diseases  to  which  it  refers.  It  cannot  be 
too  clearly  understood  that  the  science  of  gastric  diagnosis  is 
the  art  of  taking  trouble,  that  it  is  at  all  times  diametrically 
opposed  to  guess-work,  and  that  an  accurate  recognition  of  the 
nature  of  a  complaint  is  the  only  possible  basis  for  curative 
treatment. 

One  of  the  most  interesting  varieties  of  dyspepsia  is  that 
which  ensues  from  a  continuous  secretion  of  the  gastric  juice. 


lO  PREFACE. 

Hitherto  it  has  been  the  custom  to  regard  this  hypersecretion 
as  a  primary  neurosis  of  the  stomach,  but  there  can  be  httle 
doubt  that  it  is  really  a  secondary  phenomenon  dependent 
upon  an  organic  lesion  of  the  digestive  organs.  It  is  in  this 
connection  that  the  relationship  of  latent  disease  of  the  appen- 
dix vermiformis  to  dyspepsia  becomes  apparent,  since  in  almost 
every  instance  where  the  appendix  is  diseased  some  perversion 
of  the  gastric  secretion  may  be  detected.  Thus,  when  the 
organ  is  ulcerated  or  contains  a  calculus  a  typical  hypersecre- 
tion is  usually  found  to  exist,  while  if  it  be  merely  thickened, 
twisted,  or  adherent,  owing  to  a  previous  attack  of  acute  inflam- 
mation, a  form  of  chronic  gastritis  is  apt  to  supervene  after'  a 
time,  which  not  only  obscures  the  original  disorder  of  secre- 
tion, but  closely  simulates  the  clinical  features  of  nervous 
indigestion. 

The  long-continued  existence  in  the  stomach  of  a  hyper- 
acid fluid  is  apt  to  induce  severe  gastritis  accompanied  by 
numerous  erosions  of  the  mucous  membrane.  These  minute 
losses  of  tissue  sometimes  occasion  profuse  haemorrhages,  but 
since  they  only  appear  as  bleeding  points  when  the  stomach  is 
opened  at  operation,  the  condition  is  erroneously  ascribed  to  a 
morbid  affection  of  the  blood  vessels.  In  several  of  the  cases 
which  are  included  in  the  table  relating  to  the  etiology  of 
hypersecretion,  recimrent  attacks  of  haematemesis  and  melaena 
were  observed,  which  disappeared  along  with  the  previous 
symptoms  of  indigestion  as  soon  as  the  diseased  appendix  had 
been  removed.  A  simple  erosion  of  the  stomach  or  duodenum 
is,  however,  always  liable  to  be  converted  into  a  genuine 
perforating  ulcer  by  the  persistent  irritation  of  the  gastric 
secretion,  and  consequently  many  cases  of  primary  appendicular 
hypersecretion  are  eventually  complicated  by  these  lesions. 
The  biliary  form  of  hypersecretion  is  also  frequently  followed 
by  duodenal  ulcer  from  the  same  cause,  while  that  which  ensues 
in  the  first  instance  from  a  simple  ulcer  is  often  attended  in 
the  course  of  time  by  gall-stones  and  appendicitis.     These 


PREFACE.  II 

three  organic  complaints  appear,  therefore,  to  be  etiologically 
linked  together  by  a  secondary  perversion  of  the  gastric  secre- 
tion which  is  common  to  each.  The  occasional  failure  of 
gastro-jejunostomy  to  remove  the  symptoms  of  a  duodenal 
ulcer  is  often  attributable  to  concomitant  disease  of  the  gall- 
bladder or  appendix  which  had  been  overlooked  at  the 
operation. 

The  exact  significance  of  simple  hyperchlorhydria  is  at 
present  difficult  to  define,  since,  although  a  temporary  increase 
in  the  acidity  of  the  gastric  juice  is  of  frequent  occurrence,  it  is 
extremely  doubtful  whether  persistent  hyperacidity  ever  exists 
independently  of  hypersecretion. 

In  the  chapter  which  deals  with  gastric  myasthenia,  special 
attention  is  directed  to  the  latent  period  of  the  complaint  and  to 
the  comparative  rarity  of  true  gastrectasis.  The  subject  of 
inflammation  of  the  stomach  as  a  cause  of  dyspepsia  has  been 
condensed  to  the  smallest  possible  compass,  and  only  those 
varieties  are  described  which  are  endowed  with  practical 
interest.  If  it  were  always  borne  in  mind  that  chronic  inflam- 
mation of  the  stomach  is  invariably  due  either  to  toxic  poisoning 
or  to  serious  disease  of  some  other  vital  organ  of  the  body,  the 
term  "chronic  gastritis"  would  no  longer  be  applied  indis- 
criminately to  every  form  of  dyspepsia,  nor  would  its  existence 
be  regarded  as  a  matter  of  so  little  consequence. 

Displacements  of  the  stomach  constitute  a  subject  of  great 
clinical  interest,  to  which  either  too  much  or  too  little  importance 
is  usually  attached.  The  fact  that  gastroptosis  exists  in  many 
persons  who  never  suffer  from  dyspepsia  appears  to  indicate 
that  the  abnormal  position  of  the  stomach  is  quite  compatible 
with  perfect  digestion;  while  the  existence  of  impaired  motility 
or  of  some  secretory  disorder  in  every  case  which  exhibits 
symptoms  of  indigestion  serves  once  more  to  emphasise  the 
necessity  of  distinguishing  between  primary  diseases  and  their 
consequences.  Gastroptosis  is  so  exceptionally  frequent  in 
the  subjects  of  migraine,  that  future  investigations  will  prob- 


12  PREFACE. 

ably  demonstrate  a  causal  connection  between  the  two 
complaints. 

Special  prominence  is  accorded  to  those  varieties  of  dys- 
pepsia which  develop  during  infancy  and  old  age,  and  attention 
is  directed  to  the  pathological  changes  which  occur  in  the  mu- 
cous membrane  of  the  alimentary  tract  at  these  periods  of  life. 

Former  writers  were  wont  to  lay  much  stress  upon  sym- 
pathetic disturbances  of  the  stomach,  and  although  this  con- 
ception of  the  etiology  of  secondary  dyspepsias  has  been 
abandoned,  a  study  of  gastric  digestion  when  other  important 
viscera  of  the  body  are  attacked  by  disease  serves  to  throw  con- 
siderable light  upon  certain  vicarious  functions  of  the  stomach 
and  constitutes  a  subject  of  the  highest  practical  importance. 

Intestinal  indigestion  almost  defies  exact  clinical  analysis. 
In  addition  to  the  symptoms  that  ensue  from  the  usual  com- 
posite variety,  those  which  arise  from  a  primary  fimctional  de- 
rangement of  the  duodenum,  liver,  and  pancreas  are  accorded 
separate  descriptions,  while  a  short  account  is  given  of  those 
recurrent  attacks  of  abdominal  pain  due  to  a  tetanic  con- 
traction of  the  intestine  which  are  usually  confounded  with 
gastralgia. 

The  treatment  of  the  various  subjects  is  considered  upon 
broad  lines  and  no  attempt  is  made  to  enumerate  the  vast 
number  of  drugs  which  at  one  time  or  another  have  been  recom- 
mended for  the  relief  of  indigestion.  The  author's  sincere 
thanks  are  due  to  Dr.  Herbert  Rhodes  for  his  kind  assistance 
during  the  passage  of  the  work  through  the  press. 

W.  SOLTAU  FeNWICK. 

29  Harley  Street,  London, 
June,  1910. 


CONTENTS. 


CHAPTER  L 

PAGE 

The  Vaeieties  op  Dyspepsia  and  their  Differential  Diagnosis  ...     17 
Gastric  and  Intestinal  Indigestion — The  Causation  of  Gastric  Dys- 
pepsia— Scheme   of   Classification — The   Relative  Frequency  of  the 
Various  Functional  Disorders  of  the  Stomach — Scheme  of  Differential 
Diagnosis  of  Acute  and  Chronic  Dyspepsias. 

CHAPTER  II. 

Dyspepsia  dtje  to  Abnormalities  of  Secretion 30 

Hyperacidity:  Etiology — Symptoms — Treatment.  Hypersecre- 
tion: Acute  and  Chronic  Varieties — ^Their  Dependence  upon  Organic 
Lesions  of  the  Digestive  Tract — The  Appendicular  Form — The  Biliary 
Form — ^Hypersecretion  due  to  Ulcer — Symptoms — Complications — 
Diagnosis — ^Prognosis — ^Medical  and  Surgical  Treatment.  Achylia 
Gastrica:     Etiology — Diagnosis — Treatment. 

CHAPTER  III. 

Dyspepsia  due  to  Failure  of  the  Muscular  Power  of  the  Stomach  .  106 
Myasthenia  Gastrica:  Frequency — Influence  of  Heredity — 
Incidence  at  Different  Ages — ^Etiology — ^Primary  and  Secondary 
Varieties — Sjonptoms — ^The  Latent  Stage — ^The  Stage  of  Food — 
Stagnation — The  Stage  of  Food — Retention — ^Physical  Signs — Chem- 
istry of  Digestion — Diagnosis — ^Prognosis — Diet — Massage — ^Electric- 
ity— ^Lavage — ^Medicinal  Treatment. 

CHAPTER  IV. 

Dyspepsia  due  to  Inflammations  of  the  Stomach 145 

Acute  Gastritis:  Primary  and  Secondary  Forms — Etiology — 
Pathology — Clinical  Varieties — Simple  Acute  Gastritis — Febrile  and 
Afebrile  Forms — Diagnosis— Treatment.  Acute  Toxic  Gastritis: 
Pathology — Symptoms — ^Treatment.  Chronic  Gastritis:  Etiology 
— ^Frequency — Its  Dependency  upon  Diseases  of  Other  Viscera — Toxic 
Varieties — ^Pathology — Symptoms — Course  and  Prognosis — Diagnosis 
— Treatment — Lavage — Climate — Diet — Mineral  Waters — Drugs. 
Atrophic  Gastritis:  Etiology — ^Pathology — Clinical  Varieties — 
Prognosis — Use  of  Artificial  Digestives — Diet — Driigs. 

13 


14  CONTENTS. 

CHAPTER  V. 

Dyspepsia  due  to  Disturbances  of  the  Nervous  Mechanism  of  the 

Stomach      

Gastric  Hyperesthesia:  Etiology — Symptoms — Four  Clinical 
Stages — Physical  Signs — Diagnosis — Treatment.  Gastric  Neuras- 
thenia: Etiology — Symptoms — The  Mild  Form — The  Severe  Form 
— Complications — ^Prognosis — Diagnosis — Treatment.  Nervous  Eruc- 
tation: Etiology — Symptoms — Treatment.  Habitual  Regurgita- 
tion :     Etiology — Symptoms — Treatment. 


CHAPTER  VI. 

Dyspepsia  due  to  Displacements  of  the  Stomach 242 

Anatomical  Considerations.  Upward  Displacement:  Symptoms — 
Physical  Signs — Treatment.  Vertical  Displacement:  The  Angu- 
lar, Fish-hook  and  Straight  Forms — ^Etiology — Symptoms — ^Physical 
Signs — ^Prognosis — Diagnosis — Treatment.  Total  Descent  of  the 
Stomach  (Gastroptosis)  :  Frequency — Causation — Symptoms — The 
Dyspeptic  Form — The  Bilious  Form — The  Asthenic  Form — ^Physical 
Signs — ^Auscultatory — ^Percussion — ^Artificial  Inflation — Gastrodiaph- 
any — Complications — ^Prognosis  —  Diagnosis — Medical  and  Surgical 
Treatment. 


CHAPTER  VII. 

Dyspepsia  due  to  the  Presence  of  Foreign  Bodies  and  Living  Crea- 
tures in  the  Stomach 275 

Hair-balls — Bezoars — Gastroliths  :  Etiology — Symptoms — Com- 
plications— ^Physical  Signs — ^Treatment.  Insects:  Diptera — Cole- 
optera — Lepidoptera — ^Modes  of  Infection — Symptoms — ^Treatment. 
Slugs — Lizards — Worms — Leeches — ^Amphibious  Animals — Snakes. 


CHAPTER  VIII. 

Dyspepsia  in  Infancy  AND  Old  Age 303 

The  Dyspepsias  of  Different  Periods  of  Life.  Chronic  Gastroen- 
teritis IN  Infancy:  Frequency — Morbid  Anatomy — Pathology — 
Atrophy  of  the  Stomach  and  Intestine — Etiology — Symptoms — Chem- 
istry of  Digestion — Complications — ^Prognosis — Diagnosis — Infant 
Feeding — Gavage — ^Antiseptics — Treatment.  Senile  Dyspepsia: 
Etiology — ^Pathology — Symptoms — Treatment. 


CONTENTS.  15 

CHAPTER  IX. 

Dyspepsia  dependent  upon  Diseases  of  Other  Organs 359 

Lung  Disease — Tuberculosis.  The  Dyspepsia  of  Phthisis:  Path- 
ology— Symptoms — Treatment.  Heart  Disease — Liver  Disease — Kid- 
ney and  Urinary  Diseases — Specific  Fevers — Syphilis — Diabetes — 
Anaemia  and  Chlorosis — ^Nervous  Disease — ^Pregnancy — Drug  Dys- 
pepsias. 

CHAPTER  X. 

Intestinal  Indigestion      408 

Physiology  of  Intestinal  Digestion:  Its  Complex  Character — 
Influence  of  Gastric  Digestion — Intestinal  Compensation — Duodenal 
Intubation — Test-meals — Chemical  Examination  of  the  Faeces — 
Estimation  of  Nitrogen—Estimation  of  Fat — Carbohydrate  Fermen- 
tations— Micro-organisms.  Chronic  Intestinal  Indigestion:  Fre- 
quency —  Etiology — Symptoms  — Varieties  —  Diagnosis — Treatment. 
Duodenitis:  Etiology — Symptoms — Varieties — Relapsing  Form — Its 
Simulation  of  Gall-stones — Diagnosis — Treatment.  Chronic  Pan- 
creatitis :  Anatomy — Pathology — Symptoms  —  Chemistry — Prog- 
nosis— Medical  and  Surgical  Treatment.  Enterospasm:  Its  Reality 
— Etiology — Occurrence  in  Childhood — The  Adult  Variety — Symp- 
toms— ^Prognosis — Diagnosis — Treatment. 

Bibliography 454 

Index     463 


DYSPEPSIA. 


CHAPTER  I 


THE  VARIETIES  OF  DYSPEPSIA  AND  THEIR 
DIFFERENTIAL  DIAGNOSIS. 

The  classification  of  dyspepsia  has  always  been  a  matter 
of  the  greatest  difficulty,  and  it  only  requires  a  glance  through 
the  literature  of  the  subject  to  understand  what  an  amount  of 
ingenuity  and  trouble  has  been  expended  upon  the  problem 
of  assigning  the  various  symptoms  of  maldigestion  to  their 
proper  causes.  As  might  naturally  be  expected,  a  purely 
symptomatic  nomenclature  held  almost  undisputed  sway 
through  many  centuries;  and,  indeed,  it  was  not  until  the  study 
of  physiology  had  made  considerable  progress  that  derange- 
ments of  function  as  opposed  to  the  so-called  morbid  states 
of  the  stomach  became  clearly  recognised;  while  the  subsequent 
rapid  advance  of  pathology  helped  still  further  to  eliminate 
the  effects  of  organic  disease  and  to  establish  the  true  relation- 
ship of  gastric  inflammation  to  certain  disturbances  of  digestion. 
As  a  result  of  these  various  researches,  the  so-called  flatulent, 
acid,  and  irritative  forms  of  dyspepsia  which  were  included 
in  the  ancient  description  of  the  disease  were  superseded  by 
such  expressions  as  atonic,  inflammatory,  and  nervous  in- 
digestion, while  many  symptoms  which  had  hitherto  been 
regarded  as  gastric  in  origin  were  now  accurately  referred  to 
a  disturbance  of  the  intestinal  functions. 
2  17 


l8  THE   VARIETIES   OF   DYSPEPSIA. 

The  introduction  of  lavage  by  Kussmaul  in  1869  and  the 
subsequent  adoption  of  a  soft  tube  for  exploration  of  the 
stomach  has  led  to  a  great  increase  of  our  knowledge  respecting 
the  chemistry  of  digestion  under  both  normal  and  pathological 
conditions,  and  although  the  subject  is  still  very  obscure  and 
even  the  most  careful  and  extended  observations  upon  the 
same  disorder  bristle  with  apparent  contradictions,  it  is  yet 
possible  to  attribute  certain  subjective  phenomena  to  definite 
alterations  in  the  secretory,  motorial,  or  absorptive  functions 
of  the  alimentary  tract. 

Such  a  statement  will  probably  be  considered  far  too 
qualified,  and,  indeed,  many  modern  writers  seem  to  be  of  the 
opinion  that  experimental  research  has  not  only  solved  all  the 
problems  of  indigestion,  but  has  also  revolutionised  the  treat- 
ment of  functional  disorders  of  the  stomach.  Far  from  this 
being  the  case,  however,  it  will  be  conceded  by  most  practical 
physicians  that  many  ancient  empirical  methods  are  still  of 
the  greatest  value,  despite  the  fact  that  experiments  are  sup- 
posed to  have  proved  them  to  be  unscientific  in  origin  and 
useless  in  application.  In  like  manner,  attempts  to  treat  dis- 
orders of  digestion  upon  lines  laid  down  in  the  laboratory 
reveal  still  further  discrepancies  between  what  the  human 
stomach  is  expected  to  do  and  what  it  actually  does,  with  the 
result  that  the  various  artificial  aids  to  digestion,  drugs  that 
are  supposed  to  control  gastric  secretion  and  motility,  as  well 
as  the  numerous  foods  that  have  been  prepared  so  as  to  ensure 
their  immediate  absorption,  although  excellent  in  their  way, 
are  all  found  in  practice  to  possess  one  inherent  drawback — 
they  seldom  do  what  is  expected  of  them.  This  failure  of 
clinical  experience  to  corroborate  the  deductions  from  phys- 
iological research  is  obviously  due  to  the  profound  difference 
that  exists  between  the  subjects  of  the  two  classes  of  experi- 
ment— a  healthy  dog  and  an  unhealthy  man.  In  my  opinion 
two  elementary  distinctions  must  always  exist  between  an 
animal  used  for  such  experiments  and  a  dyspeptic  individual, 


DIFFERENTIAL  DIAGNOSIS.  I9 

namely,  the  absence  of  psychical  influences  in  the  animal  and 
the  invariable  disturbance  of  all  the  functions  of  the  human 
stomach  which  ensues  from  the  derangement  of  one.  In  the 
case  of  the  animal  the  stomach  is  perfectly  healthy,  and  in  so 
far  as  psychical  influences  are  concerned  the  organ  is  practically 
a  machine.  But  in  the  human  subject  the  all-controlling 
influence  of  the  nervous  system  is  perpetually  in  evidence, 
altering  the  composition  of  the  various  secretions,  exciting  or 
inhibiting  peristalsis,  and  retarding  or  accelerating  absorption 
through  the  influence  of  accidental  psychical  impressions  or 
as  the  result  of  some  constitutional  defect  of  the  organism. 
This  all-powerful  nervous  influence  constitutes  the  greatest 
obstacle  to  the  treatment  of  every  form  of  dyspepsia,  and  its 
existence  in  the  human  subject  is  of  itself  sufiicient  to  nullify 
most  of  the  conclusions  which  might  otherwise  have  been 
drawn  from  experimental  research. 

A  simple  clinical  illustration  will  suffice  to  make  this  fact 
clear.  In  the  disorder  which  is  known  as  hypersecretion, 
careful  dieting  and  treatment  will  usually  secure  immunity 
from  pain,  vomiting,  and  other  symptoms  for  a  considerable 
time,  while  repeated  analyses  of  the  gastric  contents  show  a 
corresponding  diminution  of  the  acid  secretion.  But  if  during 
this  period  of  latency  the  patient  sustains  a  physical  shock, 
experiences  some  violent  emotion,  or  even  receives  depressing 
news,  the  former  symptoms  will  recur  within  an  hour  or  two, 
spasmodic  closure  of  the  pylorus  produces  food  retention,  a 
marked  increase  of  hydrochloric  acid  occurs,  and  not  infre- 
quently a  serious  attack  of  gastric  intolerance  supervenes. 
This  sequence  of  events  is  not  the  exception,  but  the  rule;  and 
it  is  highly  probable  that,  were  it  not  for  the  intimate  connection 
between  the  secretory  activity  of  the  stomach  and  the  central 
nervous  system,  hypersecretion  would  usually  be  susceptible 
of  cure. 

But  the  second  distinction  is  of  equal  importance.  The 
term  dyspepsia,  if  it  means  anything,  is  an  acknowledgment 


20  THE   VARIETIES    OF   DYSPEPSIA. 

of  a  disorder  of  the  gastric  functions,  and  consequently  the 
results  of  experiments  conducted  upon  a  healthy  stomach, 
whether  it  belongs  to  an  animal  or  to  a  man,  can  never  logically 
be  compared  with  those  obtained  from  the  viscus  in  a  state  of 
disease.  Moreover,  there  is  no  such  thing  as  a  derangement 
of  a  single  function  of  the  stomach,  for  it  can  easily  be  proved 
that  the  slightest  disturbance  of  any  portion  of  the  intricate 
machinery  of  digestion  will  throw  out  of  gear  the  entire 
mechanism,  and  that  an  alteration  of  secretion,  for  example, 
is  soon  followed  by  a  perversion  of  motihty  and  sensibihty,  as 
well  as  by  a  profound  derangement  of  the  intestinal  functions. 
In  illustration  of  these  facts  the  condition  known  as  subacidity 
may  be  instanced.  Pawlow  has  shown  that  in  a  dog  the 
strongest  stimulants  of  gastric  secretion  are  water  and  meat 
extract,  and  it  has  consequently  been  assumed  that  the  ad- 
ministration of  soup  or  broth  at  the  commencement  of  a  meal 
should  excite  both  the  appetite  and  the  gastric  secretion  of  a 
person  suffering  from  this  chemical  indication  of  impaired 
digestion.  But  in  cases  of  gastric  subacidity  the  perversion 
of  secretion  is  not  a  primary  complaint,  but  is  usually  an  ex- 
pression of  chronic  inflammation  of  the  stomach  attended  by 
an  impairment  of  motility  and  other  abnormal  conditions  of 
the  digestive  organs.  It  is,  therefore,  invariably  found  that  the 
administration  of  water  or  broth  at  the  commencement  of  a 
meal  in  such  cases  not  only  destroys  any  remnant  of  appetite 
that  may  have  existed,  but,  by  diluting  the  already  enfeebled 
gastric  secretion  and  distending  the  too  distensible  stomach, 
intensifies  the  very  symptoms  which  the  treatment  was  intended 
to  allay. 

It  would  appear  that  Abernethy  foresaw  the  future  in- 
fluence of  theoretical  teaching  upon  medical  practice  when  he 
uttered  the  well-known  words,  "The  stomach  is  neither  a 
stew-pan  nor  a  test-tube,  but  a  stomach." 

The  Varieties  of  Dyspepsia. — Dyspepsia  may  ensue 
from  a  disorder  of  any  part  of  the  digestive  tract  or  of  the 


THE    VARIETIES    OF    DYSPEPSIA.  21 

various  organs,  whose  secretions  are  necessary  to  the  solution 
and  absorption  of  the  food.  Two  primary  varieties  must, 
therefore,  be  recognised,  the  gastric  and  the  intestinal. 

Gastric  dyspepsia  may  arise  in  many  different  ways.  Thus, 
if  the  secretion  of  the  organ  be  poured  out  in  insufficient 
quantity  or  if  it  be  lacking  in  hydrochloric  acid,  the  carbo- 
hydrate constituents  of  the  meal  will  undergo  excessive  fer- 
mentation with  the  production  of  various  gases  and  organic 
acids;  while  an  excess  of  hydrochloric  acid  causes  the  stomach 
to  empty  itself  more  rapidly  than  usual  or  produces  a  painful 
spasm  of  the  pyloric  muscle.  In  like  manner,  a  continuous 
secretion  of  gastric  juice  deprives  the  viscus  of  its  necessary 
periods  of  rest  and,  by  irritation  of  the  mucous  membrane, 
occasions  severe  discomfort  and  secondary  inflammation  of 
the  organ.  Enfeeblement  of  the  muscular  coat  of  the  stomach 
causes  food  to  stagnate  and  to  undergo  decomposition,  the 
gaseous  products  of  which,  by  distending  the  organ  and 
stretching  its  tissues,  still  further  diminish  its  muscular  power. 
Derangements  of  the  nervous  mechanism  are  more  obscure 
in  their  effects  than  other  fimctional  disorders,  but  it  is  certain 
that  an  exalted  sensibility  of  the  gastric  mucosa  is  attended 
by  severe  pain  immediately  food  is  brought  into  contact  with 
the  abnormally  sensitive  structure;  while  interference  with 
the  adequate  closure  of  the  cardiac  orifice  causes  the  constant 
regurgitation  of  small  quantities  of  chyme.  A  mixed  neurosis 
affecting  both  sensation  and  motility,  and  accompanied  by 
symptoms  of  general  neurasthenia,  constitutes  the  obscure  and 
complex  disorder  known  as  neurasthenia  gastrica  or  nervous 
dyspepsia.  Alterations  in  the  position  of  the  stomach,  whether 
congenital  or  acquired,  oppose  a  mechanical  obstacle  to  the 
propulsion  of  food  into  the  duodenum,  and  by  causing  secondary 
perversions  of  the  other  gastric  functions  may  give  rise  to  a 
form  of  dyspepsia  which  can  only  be  distinguished  from 
gastric  neurasthenia  by  careful  examination  of  the  abdomen. 
But  in  addition  to  primary  aberrations  of  function  and  to 


22  THE   VARIETIES    OF   DYSPEPSIA. 

abnormalities  of  position,  the  stomach,  like  other  organs  of 
the  body,  is  extremely  liable  to  suffer  from  inflammation,  the 
result  of  which  is  to  diminish  both  its  secretory  and  motorial 
activity  and  to  increase  the  sensibility  of  its  inner  surface. 
The  dyspeptic  symptoms  that  ensue  from  gastritis  are  con- 
sequently of  a  mixed  type  and  liable  to  become  chronic  owing 
to  the  organic  changes  which  occur  in  the  mucous  membrane. 
All  substances  that  find  their  way  into  the  stomach  do  not 
necessarily  contribute  to  the  nourishment  of  the  body,  and  if, 
owing  to  their  nature,  size,  or  consistency,  they  remain  for  a 
long  time  in  the  viscus,  they  are  apt  to  set  up  violent  irritation 
accompanied  by  the  symptoms  of  persistent  indigestion.  The 
occasional  formation  of  hair-balls  and  other  concretions  in  the 
stomach  should,  therefore,  be  considered  in  every  etiological 
study  of  dyspepsia,  as  well  as  the  existence  of  living  creatures, 
such  as  maggots,  larvae,  beetles,  and  other  insects,  which 
sometimes  find  harbourage  in  the  organ.  Lastly,  it  is  con- 
venient, from  a  clinical  stand-point,  to  notice  those  types  of 
dyspepsia  which  occur  in  infancy  and  old  age,  as  well  as  the 
various  functional  and  organic  lesions  of  the  stomach  that 
ensue  from  disease  of  other  viscera  of  the  body.  Such,  then, 
is  briefly  the  scheme  which  I  shall  adopt  in  the  clinical  de- 
scription of  that  complex  collection  of  symptoms  which  con- 
stitutes what  is  commonly  known  as  dyspepsia  or  indigestion. 

The  Classification  of  Dyspepsia: 
{A)  Gastric  indigestion. 
(i)  Disorders  of  Secretion. 
(a)  Hyperacidity  or  an  increase  of  hydrochloric  acid. 
ih)  Hypersecretion  or  continuous  gastric  secretion, 
(c)  Subacidity  (achylia)  or  diminished  gastric  secretion. 

(2)  Disorders  of  Motility. 
Myasthenia   gastrica    (atonic    dyspepsia)  or  enfeeble- 
ment  of  the  muscular  coat  of  the  stomach. 


THE    VARIETIES    OF    DYSPEPSIA.  23 

(3)  Disorders  of  the  Nervous  mechanism. 

(a)  Hyperaesthesia  of  the  stomach  or  exalted  sensibility 
of  the  mucous  membrane. 

(&)  Neurasthenia  gastrica  (nervous  dyspepsia)  or  loss 
of  nervous  energy. 

(c)  Nervous  eructation  and  regurgitation  from  interfer- 
ence with  the  closure  of  the  cardiac  orifice. 

(4)  Dyspepsia  due  to  Inflammation  of  the  stomach. 

(a)  Acute  gastritis. 

(b)  Chronic  gastritis. 

(c)  Atrophic  gastritis. 

(5)  Dyspepsia  dependent  upon  displacements  of  the  stomach. 

Gastroptosis. 

(6)  Dyspepsia  due  to  the  presence  of  Foreign  Bodies  and 
Living  Creatures  in  the  stomach. 

(7)  Dyspepsia  peculiar  to  Infancy  and  Old  Age. 

(8)  Dyspepsia  due  to  Diseases  of  Other  Organs. 

(B)  Intestinal  indigestion. 

In  order  to  determine  the  proportionate  frequency  of  the 
various  forms  of  dyspepsia  included  in  this  scheme  of  classi- 
fication, I  have  analysed  the  notes  of  five  hundred  hospital 
patients  suffering  from  indigestion,  who  came  under  my  notice 
in  the  course  of  eighteen  months,  and  also  those  of  an  equal 
number  of  dyspeptics  who  consulted  me  privately  during  the 
same  period  of  time,  and  have  arranged  them  in  the  table  on 
the  following  page. 

The  first,  or  hospital  series,  probably  indicates  with  a  fair 
degree  of  accuracy  the  relative  frequency  with  which  the 
different  types  of  the  complaint  are  met  with  in  general  practice; 
while  the  second,  or  private  series,  represents  the  subject  from 
the  point  of  view  of  the  specialist. 


24 


THE   VARIETIES    OF   DYSPEPSIA. 


AN  ANALYSIS  OF  ONE  THOUSAND  CASES  OF  DYSPEPSIA 
ARRANGED  ACCORDING  TO  THEIR  CAUSE. 


Cause 

Hospital  cases 

Private  cases 

Total 

Per  cent. 

Total 

Per  cent. 

Hyperacidity 

Hypersecretion 

Myasthenia  gastrica  .  .    . 
Hyperaesthesia  gastrica.  . 
Neurasthenia  gastrica  .  . 

Acute  gastritis 

Chronic  gastritis 

Gastroptosis 

Intestinal  indigestion  .    . 

24 

25 
160 

51 
15 
71 
72 

15 
67 

4.8 

5 
32 
10.2 

3 
14.2 
14.4 

3 
13-4 

46 

162 

26 

8 

66 

62 
88 

42 

9.2 
32.4 

5-2 

1.6 
13.2 

12.4 

17.6 

8.4 

Totals  ...... 

500 

100 

500 

100 

As  might  have  been  expected,  dyspeptic  conditions  among 
the  poorer  classes  are  most  frequently  due  to  that  enfeebled 
condition  of  the  musculature  of  the  ahmentary  tract  which 
results  from  bad  hygiene,  exhausting  occupations,  and  badly 
cooked  food,  or  from  inflammation  of  the  stomach  engendered 
by  visceral  diseases,  the  abuse  of  stimulants  or  frequent 
exposure  to  cold. 

On  the  other  hand,  the  specialist  rarely  sees  such  forms  of 
indigestion  as  hyperaesthesia. and  acute  gastritis,  which  either 
pursue  a  brief  course  or  are  readily  cured  by  treatment;  while 
the  majority  of  the  cases  that  come  under  his  notice  consist  of 
the  more  obscure  varieties,  such  as  hypersecretion  and  gas- 
troptosis, or  of  those  which  are  pecuharly  intractable  to  treat- 
ment, hke  chronic  gastritis  and  neurasthenia  gastrica. 

In  order  to  formulate  a  scheme  of  differential  diagnosis  it  is 
necessary  in  the  first  instance  to  divide  cases  of  dyspepsia  into 


THE    VARIETIES    OF    DYSPEPSIA.  25 

two  classes:  the  acute  and  the  chronic;  the  former  of  which  in- 
cludes those  varieties  that  commence  suddenly  and  endure  for 
a  limited  period  of  time,  while  the  latter  comprises  all  those 
which  are  more  or  less  permanent  in  character. 

The  class  of  acute  dyspepsias,  strictly  speaking,  only  includes 
two  forms,  namely,  acute  gastritis  and  acute  hypersecretion;  but 
inasmuch  as  the  disorder  known  as  migraine  is  accompanied 
by  very  similar  symptoms  and  is  usually  regarded  by  patients 
as  a  form  of  indigestion,  it  is  advisable  to  place  it  in  the  same 
category.  These  three  diseases  have  certain  general  symptoms 
in  common:  they  all  commence  abruptly,  pursue  a  definite 
course,  and  exhibit  a  tendency  to  periodic  recurrence.  They 
are  all  attended  by  more  or  less  epigastric  discomfort,  nausea, 
vomiting,  headache,  anorexia,  and  constipation,  and  in  each 
the  digestive  disturbance  is  sufficiently  severe  to  render  it  a 
matter  of  grave  concern  to  the  individual  affected.  It  may  be 
observed,  however,  that  while  in  gastritis  and  hypersecretion 
the  initial  symptoms  are  invariably  referred  to  the  stomach, 
violent  headache  is  always  the  first  manifestation  of  an  attack 
of  migraine.  The  mere  history  of  the  case  will  therefore 
permit  immediate  recognition  of  the  nervous  disorder.  On 
the  other  hand,  the  symptoms  of  gastritis  and  hypersecretion 
are  so  much  alike  in  their  general  characters  that  the  most 
careful  attention  to  a  patient's  description  of  his  attack  will 
fail  to  afiford  a  definite  clue  to  the  nature  of  his  malady.  Ex- 
amination of  the  vomit,  however,  will  at  once  serve  to  dis- 
tinguish acute  inflammation  of  the  stomach  from  acute  hyper- 
secretion. Thus,  in  gastritis  the  ejecta  are  scanty,  alkaline  in 
reaction,  and  composed  entirely  of  tenacious  mucus;  while  in 
acute  hypersecretion  the  vomit  consists  of  an  acid  liquid 
tinged  with  bile  or  brown  from  altered  blood,  and  which,  when 
tested  with  red  congo-paper,  is  found  to  contain  free  hydro- 
chloric acid.  The  presence  of  the  free  mineral  acid  in  the 
ejecta  is  pathognomonic  of  hypersecretion. 

The  principal  forms  of  chronic  dyspepsia  are  accompanied 


26  TBE   VARIETIES   OF   DYSPEPSIA. 

by  symptoms  so  similar  in  character  that  at  first  sight  it  would 
appear  almost  impossible  to  express  their  differential  diagnosis 
in  a  simple  manner;  yet  I  venture  to  believe  that  if  care  be 
taken  to  emphasize  certain  minor  peculiarities,  very  little 
difficulty  will  be  experienced  in  distinguishing  one  from  another. 
The  first  point  that  requires  attention  is  the  time  which  usually 
elapses  between  the  ingestion  of  solid  food  and  the  develop- 
ment of  the  first  symptom  of  indigestion,  since  it  is  found  that 
in  certain  disorders  pain  or  discomfort  ensues  immediately 
after  a  meal,  while  in  others  it  is  postponed  for  an  hour  or 
longer.  Thus,  when  pain  or  uneasiness  occurs  at  once,  the 
gastric  mucous  membrane  is  either  hyperssthetic  or  the  mus- 
cular coat  of  the  stomach  is  enfeebled;  the  pain  in  the  first 
case  being  due  to  the  contact  of  food  with  the  sensitive 
structure,  while  in  the  latter  a  feeling  of  distention  and  dis- 
comfort arises  from  the  presence  of  gas  in  the  otherwise  empty 
organ. 

Again,  there  are  three  varieties  of  dyspepsia  in  which  the 
initial  pain  or  discomfort  is  delayed  for  one  hour  or  longer 
after  the  ingestion  of  solid  food,  namely,  chronic  gastritis, 
hyperacidity,  and  chronic  hypersecretion;  in  the  first-named  of 
which  flatulent  distention  from  food  decomposition  is  the 
cause  of  the  symptom,  while  in  the  other  two  the  existence  of 
an  abnormally  acid  gastric  juice  irritates  the  gastric  mucosa 
and  excites  a  painful  spasm  of  the  pylorus. 

In  a  third  series  of  cases,  of  which  gastric  neurasthenia  and 
gastroptosis  are  the  best  examples,  the  dyspeptic  phenomena 
are  so  irregular  in  their  appearance  and  diverse  in  character 
that  their  mere  description  by  the  patient  is  usually  sufficient 
to  indicate  their  probable  causation. 

Turning  now  to  the  first  class  in  which  indigestion  ensues 
immediately  after  a  meal,  it  is  to  be  noticed  that,  whereas  al- 
most every  case  of  gastric  hyperaesthesia  is  accompanied  by 
vomiting,  this  symptom  is  entirely  absent  in  uncomphcated 
examples  of  myasthenia,  so  that  it  is  merely  necessary  to 


THE    VARIETIES    OF    DYSPEPSIA.  27 

enquire  concerning  the  occurrence  of  emesis  to  distinguish  at 
once  between  the  two  disorders. 

Again,  in  the  second  class  where  pain  or  discomfort  is 
deferred  for  one  hour  or  more  after  a  meal,  the  presence  or 
absence  of  vomiting  once  more  affords  an  important  clue  to 
the  nature  of  the  complaint,  since  emesis  never  occurs  in  simple 
hyperacidity,  but  is  a  common  feature  of  both  chronic  gastritis 
and  hypersecretion.  But  it  has  already  been  mentioned  that 
an  examination  of  the  vomit  serves  to  distinguish  injflammation 
of  the  stomach  from  continuous  secretions,  since  in  the  former 
the  ejecta  are  composed  of  alkaline  mucus,  while  in  the  latter 
they  consist  of  gastric  juice  containing  free  hydrochloric  acid. 
Here,  again,  a  differential  diagnosis  can  be  made  with  the 
greatest  simplicity. 

Finally,  when  dyspepsia  is  due  to  gastric  neurasthenia  or 
to  gastroptosis,  an  examination  of  the  abdomen  permits  the 
latter  complaint  to  be  recognised  immediately.  These  various 
considerations  can  be  expressed  more  precisely  in  the  following 
manner : 

The  DYSPEPSIA  has  commenced  in  an  acute  manner  :  The 
disease   is   either  acute  gastritis,  acute  hypersecretion,  or 
migraine, 
(i)  Severe    headache    is    the    first    symptom.     Diagnosis: 

Migraine. 
(2)  Epigastric  pain  or   discomfort   is   the   first   symptom: 
Acute  gastritis  or  hypersecretion, 
{a)  The  vomit  consists  of  thick,  bile-stained,  or  colourless 
mucus,   which   is  rejected  at   intervals   after  much 
nausea,  straining,  and  salivation,  the  material  being 
alkaline  in  reaction.     Diagnosis:  Acute  gastritis. 
(&)  The  vomit  is  profuse,  liquid,  bile-stained,  or  brown, 
rejected  at  intervals  with  much  epigastric  pain  and 
followed  by  burning  sensations  behind  the  sternum 
and  scalding  of  the  throat,  the  material  being  acid  in 


28  THE   VARIETIES    OF   DYSPEPSIA. 

reaction  and  containing  free  hydrochloric  acid  (turns 
red  congo-paper  blue).  Diagnosis:  Acute  hyper- 
secretion. 

The  dyspepsia  is  chronic  in  character. 

(i)  Pain  or  discomfort  ensues  immediately  after  food:  Gas- 
tric hypersesthesia  or  Gastric  myasthenia. 

(a)  Vomiting  is  a  frequent  symptom,  but  does  not  afford 
much  relief.  The  patient  is  usually  a  young  woman, 
anaemic  and  very  constipated.  Llilk  and  hot  fluids 
occasion  as  much  pain  as  solids;  the  entire  stomach 
is  tender  on  pressure,  and  the  symptoms  are  rapidly 
removed  by  aperients  and  full  doses  of  iron.  Diag- 
nosis :  Gastric  hyperesthesia. 

(b)  Vomiting  is  absent.  Both  sexes  are  equally  affected; 
liquids  produce  more  discomfort  than  solids;  flatulence 
is  excessive;  clapotage  may  be  obtained  during  the 
whole  period  of  digestion.  Diagnosis:  Gastric 
myasthenia  (atony). 

(2)  One  hour  or  longer  elapses  before  pain  or  discomfort 
develops:  the  disorder  is  chronic  gastritis,  hyperacidity, 
or  chronic  hypersecretion. 

{a)  There  is  no  vomiting.     Diagnosis:  Hyperacidity. 
{b)   Vomiting   is   a  feature  of  the  complaint:  it  may  be 
gastritis  or  hypersecretion. 
{a')  The  vomit  in  the  early  morning  is  sticky,  scanty, 
and  alkaline,  while  that  after  meals  is  composed  of 
undigested  food  mixed  with   a  large  amount  of 
glairy  mucus  from  which  free  hydrochloric  acid  is 
absent.     Diagnosis:  Chronic  gastritis. 
(&')  The  vomit  is  profuse,  liquid,  acid  to  litmus-paper, 
and  contains /ree  hydrochloric  acid  (turns  red  congo- 
paper  blue) .  Diagnosis :  Chronic  hypersecretion. 

(3)  The  discomfort  develops  at  irregular  intervals,  varies  in 
severity  from  day  to  day  with  the  same  diet,  and  is 


THE    VARIETIES    OF    DYSPEPSIA.  29 

accompanied  by  numerous  nervous  phenomena.     The 
stomach   is  normal   in   size    and   position.     Diagnosis: 
Gastric  neurasthenia. 
The  symptoms  are  similar  to  the  last,  but  the  stomach 
is  found  dislocated  downward  in  the  abdomen.     Diag- 
nosis: Gastroptosis. 


CHAPTER  II. 

DYSPEPSIA  DUE  TO  ABNORMALITIES  OF  THE 
GASTRIC  SECRETION. 

(i)  Hyperacidity.     (2)  Hypersecretion.     (3)  Achylia 
Gastrica. 

I.    HYPERACIDITY. 

(Synonyms — Hyperchloracidity;    -Superacidity;    Hyperchlor- 

hydria.) 

The  term  "hyperacidity"  is  applied  to  a  variety  of 
dyspepsia,  the  principal  symptoms  of  which  are  due  to  an 
excessive  secretion  of  hydrochloric  acid  during  the  period  of 
gastric  digestion,  the  phenomenon  disappearing  as  soon  as  the 
stomach  has  become  empt}^ 

Frequency. — Owing  to  the  fact  that  a  systematic  analysis 
of  the  gastric  contents  in  cases  of  dyspepsia  is  rarely  performed 
either  in  private  or  hospital  practice,  it  is  almost  impossible 
to  obtain  any  rehable  information  concerning  the  frequency 
of  the  disorder,  and  most  writers  content  themselves  with  the 
statement  that  it  is  a  common  complaint.  According  to  most 
German  authorities,  h}'peracidity  exists  in  about  one-half  of  all 
persons  who  suffer  from  functional  disturbances  of  digestion, 
but  Jaworski  states  that  it  existed  in  75  per  cent,  of  his  patients 
who  had  diseases  of  the  stomach.  In  France,  Mathieu  and 
Remond  noted  its  existence  in  about  30  per  cent,  of  the  cases 
of  dyspepsia  which  they  examined,  and  Bouveret  in  25  per 
cent,  of  those  that  came  under  his  immediate  care.  Einhorn, 
of  New  York,  states  that  it  was  present  in  286  out  of  564  cases 
of  indigestion,  or  in  more  than  50  per  cent.;  but  in  London  it 
would  seem  that  the  complaint  is  much  less  frequent,  since  it 

30 


ETIOLOGY.  31 

was  only  observed  in  9 . 2  per  cent,  of  my  private  cases  and  in 
4.8  per  cent,  of  those  examined  at  the  London  Temperance 
Hospital. 

Etiology. — An  excessive  secretion  of  hydrochloric  acid 
during  the  period  of  digestion  occurs  under  many  and  diverse 
conditions.  Thus,  it  may  ensue  from  direct  stimulation  of 
the  mucous  membrane  of  the  stomach  or  from  irritation  of  a 
neighbouring  or  even  remotely  situated  organ.  It  is  a  fre- 
quent accompaniment  of  gastric  ulcer  and  gastroptosis,  and  is 
occasionally  met  with  in  other  functional  and  organic  lesions 
of  the  stomach,  while  in  many  diseases  of  the  central  nervous 
system  the  severity  of  the  secondary  hyperchlorhydria  often 
distracts  attention  from  the  more  important  primary  trouble. 
It  is,  therefore,  convenient  to  distinguish  between  a  primary 
and  a  secondary  variety,  according  as  the  complaint  appears 
as  a  simple  functional  derangement  of  the  stomach  or  as  a 
complication  of  a  more  serious  affection  either  of  that  viscus 
or  some  other  organ  of  the  body. 

Primary  Hyperacidity. — The  most  frequent  cause  of  the 
primary  variety  is  to  be  found  in  a  prolonged  and  excessive 
stimulation  of  the  gastric  mucous  membrane  by  the  ingesta. 
The  introduction  into  the  stomach  of  a  large  quantity  of 
nitrogenous  food  induces  in  a  healthy  individual  a  secretion 
of  gastric  juice  sufficiently  abundant  to  meet  the  demands 
made  upon  the  digestive  capabilities  of  the  organ,  the  larger 
the  meal  the  more  profuse  and  potent  being  the  gastric  secre- 
tion. It  consequently  happens  that  persons  who  habitually 
indulge  in  abnormal  quantities  of  rich  food  educate  their 
stomachs  to  produce  at  each  meal  a  secretion  which  is  not 
only  unduly  abundant,  but  which  is  also  particularly  rich 
in  hydrochloric  acid.  As  long  as  the  supply  of  food  continues, 
this  inordinate  activity  of  the  stomach  rarely  produces  any 
ill  effects;  but  if,  from  any  cause,  the  diet  is  suddenly  restricted 
the  excess  of  free  hydrochloric  acid  at  once  makes  itself  felt 
by  pain,  pyrosis,  and  other  symptoms  of  indigestion.     It  is  for 


32  HYPERACIDITY. 

this  reason  that  so  many  bon  vivants  suffer  from  "acid"  dys- 
pepsia, when,  owing  to  an  attack  of  gout  or  other  disease,  they 
are  obHged  to  confine  themselves  to  a  hmited  dietary. 

In  other  instances  it  is  the  quality  rather  than  the  quantity 
of  the  food  which  is  responsible  for  the  over-excitation  of  the 
gastric  glands.  Thus,  in  many  cases  the  hyperacidity  can  be 
traced  to  indulgence  in  condiments,  spices,  coffee,  wines,  beer, 
liqueurs,  tea,  sweets,  liver,  bacon,  or  salt  fish;  while  in  certain 
individuals  a  strong  cigar  or  an  excess  of  tobacco,  a  few  doses 
of  gentian,  quinine,  quassia,  nux  vomica,  iodide  of  potassium 
or  sandalwood  oil,  or  even  a  mercurial  pill  invariably  pro- 
duces an  attack  of  the  disorder. 

Insufficient  mastication  of  ordinary  food,  whether  it  be 
from  carelessness  or  absence  of  teeth,  is  another  common  cause 
of  hyperacidity,  while  among  the  poorer  classes  inefficient 
cooking,  coarse  bread,  oatmeal,  and  excess  of  hard  vegetables 
are  often  the  exciting  agents  of  the  complaint.  According  to 
my  experience,  vegetarians  are  especially  prone  to  suffer  from 
this  variety  of  indigestion  after  middle  age. 

All  authorities  are  agreed  that  a  hyperacid  secretion  of 
the  stomach  is  often  due  to  functional  disorders  of  the  central 
nervous  system,  and  is  common  in  families  which  possess  an 
inherited  tendency  to  mental  disease,  hysteria,  or  epilepsy. 
The  subjects  of  neurasthenia  are  particularly  prone  to  chronic 
hyperacidity,  and  von  Noorden  has  noted  its  prevalence  in 
cases  of  melancholia.  Psychic  influences  are  often  the 
exciting  cause  of  an  attack  in  nervous  individuals,  a  sudden 
emotion,  such  as  worry,  anger,  or  excitement,  being  at  once 
followed  by  the  symptoms  of  the  gastric  disorder.  Finally,  any 
condition  which  tends  to  exhaust  the  nervous  system,  such  as 
insufficient  food,  bad  ventilation,  a  residence  in  an  atmosphere 
which  is  constantly  illuminated  by  gas,  masturbation,  venereal 
excesses,  bleeding  piles,  epistaxis,  menorrhagia,  or  even 
profuse  leucorrhoea,  are  frequent  though  often  unsuspected 
causes  of  chronic  hyperacidity  in  early  life. 


ETIOLOGY.  33 

Secondary  hyperacidity  is  somewhat  less  common  than  the 
primary  form.  It  exists  in  more  than  one-half  of  all  cases  of 
chronic  simple  ulcer  of  the  stomach  and  duodenum,  and  is 
especially  common  when  the  ulcer  is  situated  in  the  immediate 
vicinity  of  the  pylorus.  It  is  occasionally,  though  rarely, 
met  with  in  cancer  and  sarcoma  of  the  same  region.  Chronic 
irritation  in  other  abdominal  organs  may  also  be  accompanied 
by  hyperacidity  of  the  gastric  secretion,  which  is  therefore  by 
no  means  infrequent  in  persons  suffering  from  floating  kidneys, 
displaced  or  inflamed  ovaries,  ovarian  tumours  that  are  liable 
to  torsion  of  their  pedicles,  retroverted  uterus,  chronic  peri- 
metritis, and  certain  spasmodic  affections  of  the  colon.  The. 
1  subjects  of  gall-stones  are  particularly  prone  to  this  variety  1 
\  of  dyspepsia  and  during  an  attack  of  biliary  colic  will  often  \ 
\  vomit  gastric  juice  that  contains  an  abnormally  high  per- 
centage of  free  hydrochloric  acid.  A  similar  phenomenon  is 
sometimes  observed  during  the  passage  of  a  renal  or  pancreatic 
calculus. 

Jaundice  due  to  obstruction  of  the  com.mon  bile  duct  is 
usually  associated  with  the  symptoms  of  dyspepsia  and 
occasionally  by  the  signs  of  hyperacidity.  This  fact  is  cor- 
roborated to  some  extent  by  the  experiments  of  Smitzky,  who 
found  that  ligature  of  the  bile-duct  in  dogs  was  followed  by  an 
excessive  secretion  of  hydrochloric  acid,  which  disappeared 
when  the  jaundice  subsided. 

German  writers  affirm  that  chlorosis  is  constantly  accom- 
panied by  hyperacidity,  and,  according  to  Oswald,  85  per  cent, 
of  the  subjects  of  chlorosis  in  Riegel's  clinic  suffered  from 
hyperchlorhydria.  In  this  country,  however,  the  association 
of  the  two  disorders  is  much  less  common,  and  most  of  the 
anaemic  girls  who  come  under  medical  treatment  for  dyspepsia 
suffer  either  from  myasthenia  of  the  stomach  and  bowel  or 
from  gastric  hypersesthesia. 

Organic  as  well  as  functional  diseases  of  the  brain  and 
spinal  cord  are  occasionally  attended  by  hyperacidity.     Cere- 
3 


34  HYPERACIDITY. 

bral  tumour,  chronic  cerebritis,  disseminated  sclerosis,  chronic 
myelitis,  and  locomotor  ataxia  are  especially  apt  to  be  com- 
plicated by  the  gastric  disorder,  while  attacks  of  migraine  and 
hystero-epilepsy  are  occasionally  preceded  by  the  vomiting 
of  an  abnormally  acid  gastric  juice.  Finally,  it  may  be  noted 
that  a  causal  connection  exists  between  hyperacidity  and 
malaria,  and  that  the  paroxysmal  attacks  of  the  latter  are 
sometimes  replaced  by  severe  cardialgia  accompanied  by  an 
excessive  secretion  of  hydrochloric  acid. 

The  primary  form  is  more  frequent  in  men  than  women 
and  is  most  commonly  met  with  between  thirty  and  fifty 
years  of  age,  the  average  age  at  which  the  disorder  commenced 
in  my  series  of  cases  being  forty-three  years.  Heredity 
undoubtedly  plays  an  important  part  in  its  etiology,  since  the 
disorder  is  particularly  common  in  certain  families,  every 
member  of  which  will  sometimes  develop  it  about  middle  life. 
According  to  Fleischer,  the  inhabitants  of  Hessia  are  unduly 
prone  to  suffer  from  this  disorder  of  the  stomach,  and  Jaworski 
noted  its  inordinate  frequency  among  the  natives  of  Poland. 
In  England  the  complaint  is  most  often  encountered  in  damp 
and  low-lying  districts,  along  the  southern  and  western  coasts, 
and  in  towns  whose  water  supply  is  derived  from  a  chalky  soil. 
It  is  far  more  common  among  the  upper  classes  of  society  than 
among  the  poor,  and,  according  to  my  statistics,  is  twice  as 
frequent  in  private  practice  as  among  persons  who  attend 
the  out-patient  department  of  a  hospital.  It  is  especially 
apt  to  attack  those  engaged  in  occupations  which  involve 
severe  mental  strain  or  who  suffer  continually  from  domestic, 
financial,  or  business  worries.  Jews  are  more  liable  to  it  than 
any  other  section  of  the  community. 

Symptoms. — Hyperacidity  usually  commences  in  an  insidi- 
ous manner,  and  many  weeks  or  even  months  may  elapse  before 
its  characteristic  phenomena  become  fully  developed.  Occa- 
sionally, however,  they  appear  quite  abruptly  during  perfect 
health  and,  after  continuing  severe  for  a  week  or  two,  either 


SYMPTOMS.  35 

disappear  completely  or  gradually  lessen  in  severity  and  assume 
a  chronic  form. 

Pain. — This  constitutes  the  most  frequent  and  prominent 
symptom  of  the  disorder,  and  although  it  may  vary  consider- 
ably in  intensity  in  different  cases  and  in  the  same  case  at 
different  times  it  always  presents  certain  features  which  serve  to 
distinguish  it  from  that  met  with  in  other  varieties  of  dyspepsia. 

At  an  early  stage  of  the  malady  discomfort  rather  than 
actual  pain  is  the  rule,  and  the  patient  chiefly  complains  of  a 
feeling  of  pressure,  heat  or  burning  in  the  epigastrium,  which 
culminates  in  the  expulsion  of  wind  or  slight  acid  eructations. 
In  the  course  of  time  these  subjective  phenomena  increase 
in  severity  until  they  merge  into  actual  pain.  When  this  stage 
has  been  reached,  pain  ensues  during  each  period  of  digestion 
and  usually  from  one  to  three  hours  after  the  meal.  Thus,  if 
breakfast  be  taken  at  8.30  a.m.  the  epigastric  discomfort  is 
usually  felt  about  10  a.m.  and  the  crisis  of  the  attack  is  reached 
about  II  o'clock;  while  a  lunch  at  1.30  p.m.  is  followed  by 
pain  from  3  to  4  o'clock,  and  a  dinner  at  7.30  p.m.  by  pain 
at  9.30  to  II  P.M.  As  a  rule,  the  morning  attack  is  the  slightest 
and  that  of  the  afternoon  the  most  severe;  but  those  persons 
who  make  their  principal  meal  in  the  evening  usually  suffer 
most  at  night.  It  is  also  to  be  observed  that  the  character 
of  the  food  and  the  amount  that  is  taken  exert  an  important 
influence  upon  the  time  at  which  the  pain  occurs;  the  more 
abundant  the  meal  and  the  greater  the  proportion  of  nitro- 
genous matter  it  contains,  the  later  the  development  of  the 
symptom;  while  a  small  meal,  or  one  composed  chiefly  of 
farinaceous  substances  or  vegetables,  is  often  followed  by 
pain  within  an  hour.  As  a  rule,  the  pain  is  referred  at  its 
commencement  to  the  epigastrium,  but  subsequently  it 
radiates  over  the  whole  of  the  upper  abdomen  and  lower  part 
of  the  chest,  round  the  left  hypochondrium  to  the  back,  and  is 
often  severe  in  the  region  of  the  dorsal  spine.  In  some  cases 
the  precordial  region  is  principally  affected  and  much  difl&culty 


36  HYPERACIDITY. 

may  be  experienced  in  distinguishing  the  condition  from  angina 
pectoris,  while  occasionally  the  paroxysm  appears  to  be  located 
over  the  site  of  the  gall-bladder  and  closely  resembles  an 
attack  of  biliary  colic.  When  hyperacidity  accompanies 
gastroptosis  the  pain  is  often  referred  to  the  right  ihac 
region,  and  may  consequently  suggest  renal  colic  or  appen- 
dicitis. During  the  height  of  an  attack  the  face  is  expressive 
of  the  greatest  agony,  and  the  patient  often  rolls  upon  the 
floor  or  reclines  over  the  back  of  a  chair  in  his  endeavours  to 
obtain  some  relief  from  his  intolerable  suffering.  Chilhness 
or  shivering  is  sometimes  complained  of  and  profuse  perspira- 
tions are  apt  to  occur;  but  the  temperature  of  the  body  is 
never  elevated,  and  the  pulse  is  usually  slow,  regular,  and  of 
low  tension.  Occasionally  a  patient  will  describe  a  peculiar 
sensation  of  movement  or  "jumping"  of  the  stomach,  as 
though  the  organ  was  undergoing  a  series  of  spasmodic 
contractions.  The  chmax  of  the  attack  is  usually  heralded 
by  the  belching  of  gas  and  the  regurgitation  of  mouthfuls  of 
acid  fluid  which  gives  rise  to  a  cramping  pain  behind  the 
sternum  and  scalding  of  the  throat  and  mouth,  after  which 
the  symptoms  gradually  subside  and  are  replaced  by  soreness 
and  tenderness  of  the  epigastric  and  hypochondriac  regions. 
In  some  instances  there  is  profuse  salivation.  Occasionally 
vomiting  occurs  and  is  followed  by  an  immediate  remission  of 
the  symptoms.  These  violent  attacks  do  not  exhibit  any  strict 
periodicity  of  recurrence,  but  develop  at  irregular  intervals 
during  the  course  of  the  disease,  and  often  appear  to  be 
excited  by  some  special  article  of  diet  or  by  a  severe  mental 
emotion.  The  milder  paroxysms  usually  last  from  twenty 
to  forty  minutes  and  completely  subside  before  the  next  meal, 
but  the  more  violent  may  persist  for  several  hours  and  be 
accompanied  by  severe  headache. 

Many  patients  lay  great  stress  upon  the  fact  that  the  pain 
only  occurs  when  the  stomach  is  empty,  although  they  will 
admit  that  they  never  suffer  in  this  respect  in  the  early  morning 


SYMPTOMS.  37 

before  breakfast  when  the  organ  is  really  devoid  of  food. 
This  statement  must,  therefore,  be  understood  to  imply  that 
the  pain  usually  develops  toward  the  termination  of  gastric 
digestion  and  consequently  at  a  time  when  the  stomach  is 
popularly  supposed  to  be  empty.  Cases  in  which  the  pain 
is  thus  deferred  for  several  hours  also  exhibit  another  quite 
characteristic  though  apparently  anomalous  feature,  namely, 
that  the  symptom  is  immediately  reheved  by  the  ingestion  of 
proteid  food.  The  explanation  of  this  phenomenon  is  to  be 
found  in  the  strong  chemical  affinity  that  exists  between  free 
hydrochloric  acid  and  albumin,  the  compound  formed  when 
the  two  are  brought  into  contact  being  of  considerable  sta- 
bility and  not  endowed  either  with  the  digestive  or  irritant 
properties  of  the  uncombined  mineral  acid.  A  draught  of 
water  also  affords  rehef  by  diluting  the  acid  contents  of  the 
organ,  while  a  dose  of  bicarbonate  of  sodium  or  other  alkali 
proves  still  more  effective  by  neutralising  the  free  acid. 

The  painful  sensations  which  arise  from  hyperacidity  are 
probably  due  to  several  causes.  An  excess  of  free  acid  appears 
to  increase  the  peristaltic  movements  of  the  stomach  and  at 
the  same  time  to  induce  spasm  of  the  pyloric  and  cardiac  sphinc- 
ters, the  combined  effects  of  which  augments  the  intragastric 
pressure  and  thus  to  produce  subjective  sensations  of  weight, 
fulness,  and  distention.  The  cardiac  sphincter,  being  the 
weaker  of  the  two,  usually  yields  first,  when  a  copious  eructation 
of  gas  occurs  and  immediate  relief  is  experienced.  It  is  only 
in  rare  instances  that  relaxation  of  the  pylorus  precedes  that 
of  the  cardia,  and  in  such  a  sudden,  general  distention  of  the 
abdomen  accompanied  by  griping  pains,  the  passage  of 
flatus,  and  sometimes  by  a  loose  action  of  the  bowel  replace 
the  previous  gastric  symptoms.  There  is  reason  to  believe 
that  in  chronic  cases  the  continued  overaction  of  the  pyloric 
muscle  leads  to  a  hypertrophy  of  its  tissue,  and  that  the 
violent  pain  which  sometimes  occurs  at  the  crisis  of  an  attack 
is  due  in  great  measure  to  a  tetanic  contraction  of  this  enlarged 


38  HYPERACIDITY. 

and  powerful  muscle.  But,  apart  from  these  considerations, 
it  is  quite  certain  that  an  increased  sensibility  of  the  whole  of 
the  gastric  mucosa  must  exist  in  most  cases  of  chronic  hyper- 
chlorhydria  and  play  by  no  means  an  unimportant  part  in  the 
production  of  the  gastric  pain.  Thus,  many  cases  have  been 
recorded  in  which  persistent  hyperacidity  was  not  accom- 
panied by  any  abnormal  symptoms,  and  I  have  often  found 
after  the  administration  of  a  test-meal  to  persons  who  had 
never  suffered  from  indigestion,  that  the  total  acidity  of 
the  filtrate  varied  from  75  to  90  with  a  notable  increase 
in  the  amount  of  free  hydrochloric  acid.  On  the  other  hand, 
it  is  a  still  more  common  experience  that  in  very  chronic 
cases  of  hyperchlorhydria  the  total  acidity  as  well  as  the 
percentage  of  free  acid  gradually  falls  until  a  condition  of 
subacidity  is  attained,  while  at  the  same  time  the  painful 
sensations  experienced  during  the  periods  of  digestion  are 
increased  rather  than  diminished,  and  even  the  administration 
of  bicarbonate  of  sodium  seems  further  to  exaggerate  the 
suffering.  Lastly,  in  every  case  of  this  nature  in  which  I  have 
seen  the  stomach  opened  with  the  view  of  discovering  an 
organic  cause  for  the  severe  symptoms,  the  mucous  membrane 
was  purple  in  colour,  much  swollen,  and  covered  with  numerous 
superficial  haemorrhages  or  erosions,  while  the  microscopical 
examination  of  a  small  portion  that  was  removed  showed 
severe  interstitial  gastritis  of  the  kind  that  is  artificially  pro- 
duced by  the  application  of  chemical  irritants.  I  have, 
therefore,  very  little  doubt  that  the  susceptibility  of  the  stomach 
to  free  hydrochloric  acid  varies  considerably  in  different 
individuals,  and  that  many  persons  are  able  to  endure  without 
discomfort  a  degree  of  acidity  which  in  others  invariably 
provokes  severe  suffering.  Further,  that  while  hyperaesthesia 
of  the  gastric  mucosa  always  exists  in  cases  of  hyperacidity, 
long-continued  irritation  excites  a  severe  diffuse  gastritis  which 
renders  the  organ  intolerable  of  any  degree  of  acidity,  of 
strong  alkalies,  or  even  of  food  itself. 


SYMPTOMS.  39 

Vomiting  rarely  occurs  spontaneously  in  uncomplicated 
cases,  but  the  patient  will  often  insert  his  fingers  down  the 
throat  or  adopt  some  other  means  of  emptying  the  stomach 
in  order  to  secure  the  relief  that  invariably  follows  an  evacuation 
of  the  organ.  Flatulence  is  always  present,  and  in  mild  cases 
constitutes  the  principal  symptom  of  the  complaint.  As  a 
rule,  one  hour  or  more  elapses  between  the  ingestion  of  food 
and  the  development  of  epigastric  distention  and  gaseous 
eructations.  Acidity  is  also  a  common  cause  of  complaint  and 
takes  the  form  of  regurgitations  of  an  extremely  sour  fluid, 
accompanied  by  a  scalding  or  cramping  pain  behind  the 
sternum  and  in  the  throat.  Occasionally  the  pyrosis  is  re- 
placed by  severe  aching  in  the  muscles  of  the  neck  and  in 
the  region  of  the  submaxillary  glands.  As  a  rule,  the  appetite 
remains  unimpaired  throughout  the  whole  course  of  the  malady 
and  is  often  markedly  increased.  In  other  cases  a  curious 
sense  of  emptiness  or  sinking  is  experienced  in  the  epigastrium 
one  hour  or  more  after  a  meal,  which  only  recourse  to  milk  or 
other  nitrogenous  food  will  allay,  or  an  insatiable  craving  exists 
for  meat,  accompanied,  perhaps,  by  a  distaste  for  fat,  oils,  and 
butter.  Apart  from  the  habit  so  often  acquired  of  indulging 
in  draughts  of  cold  water  with  a  view  of  relieving  the  pain, 
actual  thirst  is  rarely  a  symptom  of  the  disorder.  Constip  ation 
almost  invariably  exists,  and  the  evacuation  of  a  hard  scyb- 
alous stool  is  sometimes  followed  by  much  itching  of  the 
anus.  In  chronic  cases  attacks  of  diarrhoea  are  apt  to  super- 
vene from  time  to  time,  when  small  motions  mixed  with  much 
slimy  mucus  are  voided.  The  general  nutrition  is  wonderfully 
well  preserved,  and  even  in  severe  cases  the  patient  rarely 
loses  flesh  or  presents  the  careworn,  anaemic  appearance 
usually  met  with  in  other  painful  diseases  of  the  stomach. 
The  tongue  remains  red,  clean,  and  moist;  the  teettLure.^pt  to 
undergarapid  decay,  and  small  superficial  ulcers  occur  from 
time  to  time  upon  the  gums  and  Hps.  Hyperacidity  of  thei 
gastric  juice  is  always  accompanied  by  a  corresponding  re- 


40  HYPERACIDITY. 

duction  in  the  acidity  of  the  urine,  which  after  meals  is  often 
alkahne  in  reaction  and  deposits  phosphates  on  standing. 
According  to  Sticker,  the  output  of  chlorides  is  diminished. 

Physical  Signs. — External  examination  of  the  stomach 
rarely  reveals  any  abnormal  signs.  In  uncomplicated  cases 
the  organ  presents  no  indications  of  enlargement,  nor  can  any 
locaHsed  tenderness  be  discovered  by  palpation.  During  an 
attack  of  severe  pain,  however,  the  whole  of  the  gastric  region 
is  distended  and  extremely  sensitive  to  pressure,  especially 
over  the  site  of  the  pylorus,  and  occasionally  an  intermittent 
increase  of  resistance  over  the  fundus  suggests  the  existence 
of  an  excessive  peristalsis. 

The  passage  of  a  soft  tube  into  the  stomach  and  a  chemical 
analysis  of  the  material  extracted  is  the  only  method  by  which 
a  positive  diagnosis  of  hyperacidity  can  be  made  and  its 
severity  be  estimated.  In  the  early  morning  before  any  food^ 
or  drink  has  been  taken,  the  stomach  is  found  to  be  either! 
entirely  empty  or  at  most  to  contain  a  few  cubic  centi-' 
metres  of  an  alkaline  and  slightly  opalescent  fluid:  a  result 
which  serves  at  once  to  distinguish  hyperacidity  from  hyper- 
secretion, in  which  latter  complaint  the  fasting  stomach  always 
contains  a  notable  amount  of  gastric  juice.  A  test  break- 
fast, consisting  of  about  2^  oz.  of  soft  bread  and  12  fl.  oz. 
of  weak  tea,  with  sugar  and  milk,  is  then  administered, 
and  the  stomach  is  again  evacuated  at  the  end  of  an  hour. 
On  examination,  the  filtered  chyme  gives  the  usual  colour 
reactions  indicative  of  free  hydrochloric  acid,  and,  when  tritu- 
rated with  the  decinormal  solution  of  soda,  the  total  acidity 
is  found  to  exceed  the  normal  (55-60)  and  often  amounts  to 
85,  while  the  amount  of  hydrochloric  acid  in  a  free  state  varies 
between  o .  04  and  o .  08  per  cent.  As  a  rule,  the  proteid-acid 
exhibits  a  corresponding  degree  of  increase. 

The  filtered  fluid  also  contains  albumin  in  various  forms, 
such  as  syntonin,  propeptone,  and  peptone,  and  the  biuret 
reaction    is    usually    very   pronounced.     Lactic    and   butyric 


CLINICAL   VARIETIES.  4I 

acids  are  absent,  and  when  exposed  to  the  air  the  fluid  resists 
putrefaction  for  several  days.  It  may  also  be  determined  that 
the  material  is  capable  of  digesting  discs  of  egg  albumin  when 
maintained  at  a  temperature  of  about  70°  F.  and  will  curdle 
milk  after  neutrahsation. 

As  might  be  expected  from  the  abnormal  activity  of  the 
gastric  secretion,  the  processes  of  digestion  are  more  rapid  than 
under  ordinary  circumstances,  and  the  material  left  upon  the 
filter  displays  that  fine  subdivision  and  transparency  of  its 
constituent  particles  which  are  always  indicative  of  active 
digestion.  Absorption  from  the  stomach  is  not  disturbed  in 
uncomphcated  cases,  and  if  the  iodide  of  potassium  test  be 
employed,  the  salt  may  be  detected  in  the  saliva  within  ten 
minutes  or,  according  to  some  authorities,  even  sooner.  During 
the  earlier  stages  of-  the  complaint  the  excess  of  free  acid  in 
the  gastric  secretion  appears  to  stimulate  the  muscular  tunic, 
with  the  result  that  the  organ  empties  itself  with  unusual 
rapidity,  and,  if  the  salol  test  be  applied,  salicylic  acid  ap- 
pears in  the  urine  one  hour  and  a  half  after  the  administra- 
tion of  the  salt.  In  very  chronic  cases,  on  the  other  hand, 
gastric  myasthenia  usually  exists,  and  if  hypersecretion  com- 
plicates the  original  disorder,  dilatation  of  the  stomach  is 
always  present. 

Clinical  Varieties. — At  its  commencement  simple  hyper- 
acidity is  usually  intermittent  in  character,  and  after  an 
attack  has  lasted  for  a  few  weeks,  the  symptoms  disappear 
for  some  time.  In  many  instances  the  development  and  sub- 
sidence of  the  complaint  appear  inexplicable  to  the  patient, 
but,  as  a  rule,  its  recrudescence  is  attributable  either  to  an  in- 
discretion of  diet,  excitement,  fatigue,  or  to  exposure  to  cold. 
The  disorder  may  persist  in  this  intermittent  form  throughout 
the  patient's  entire  hfe. 

More  frequently,  the  attacks  tend  to  succeed  each  other 
at  shorter  and  shorter  intervals,  to  be  excited  more  readily, 
and  to  prove  more  refractory  to  treatment,  until  the  patient 


42  HYPERACIDITY. 

describes  himself  as  suffering  from  a  chronic  form  of  indigestion 
with  frequent  intercurrent  attacks  of  a  more  acute  nature. 
It  is  worthy  of  notice,  however,  that  an  examination  of  the 
contents  of  the  stomach  during  a  period  of  apparent  remission 
almost  invariably  indicates  that  the  secretion  of  hydrochloric 
acid  is  constantly  in  excess  of  the  normal. 

In  other  instances,  again,  the  gastric  attacks  are  replaced 
from  time  to  time  by  symptoms  akin  to  those  of  migraine, 
and  violent  headache,  lasting  for  several  hours,  and  sometimes 
terminating  by  vomiting,  develops  at  irregular  intervals  and 
causes  great  prostration.  In  such  cases  the  contents  of  the 
stomach  during  an  attack  always  exhibit  a  large  excess  of  free 
hydrochloric  acid. 

Lastly,  all  authorities  are  agreed  that  chronic  hyperacidity 
is  very  apt  to  be  complicated  by  hypersecretion,  the  inter- 
mittent flow  of  gastric  juice  gradually  giving  place  to  a  con- 
tinuous secretion.  At  first  the  hypersecretion,  like  its  fore- 
runner, is  usually  intermittent,  but  eventually  it  assumes  a 
chronic  character  and  is  then  attended  by  the  various  signs 
and  symptoms  characteristic  of  that  disorder.  Very  rarely 
multiple  erosions  of  the  gastric  mucous  membrane  occur  and 
give  rise  to  slight  haematemesis  or  melaena  (Oestreich). 

Prognosis. — Uncomplicated  hyperacidity,  when  properly 
treated  at  an  early  stage,  is  usually  susceptible  of  cure.  The 
chronic  form  of  the  disease,  however,  is  much  more  intractable 
and  undergoes  frequent  relapses,  but  its  principal  symptoms 
may  be  reheved  by  the  adoption  of  a  strict  diet  and  other 
remedial  measures.  When  the  disease  is  compHcated  by 
dilatation  of  the  stomach,  the  prognosis  is  much  less  favourable, 
since  it  is  apt  to  be  followed  by  the  continuous  secretion  of 
gastric  juice.  If  the  hyperacidity  is  secondary  to  organic 
disease  of  the  nervous  system,  ulcer  of  the  stomach,  chole- 
lithiasis, etc.,  the  prognosis  will  depend  upon  that  of  the 
primary  complaint. 

Diagnosis. — When   the   symptoms   of   hyperacidity    are 


DIAGNOSIS.  43 

very  pronounced,  the  history  of  the  case  affords  a  strong  in- 
dication of  the  nature  of  the  malady.  Thus,  the  onset  of 
epigastric  pain  one  or  two  hours  after  a  meal,  accompanied 
by  flatulence  and  acidity;  the  relief  that  is  afforded  by  a  dose 
of  alkaline  medicine,  or  even  by  a  glass  of  milk  or  other  proteid 
food;  the  periodic  recurrence  of  the  symptoms  and  their 
augmentation  by  certain  articles  of  diet,  fatigue,  or  excitement 
are  facts  that  must  invariably  suggest  an  hyperacid  gastric 
juice.  On  the  other  hand,  a  positive  diagnosis  can  only  be 
made  by  careful  exploration  of  the  stomach  after  a  test  meal, 
and  the  determination  thereby  of  an  excess  of  hydrochloric  acid 
in  its  secretion,  which  disappears  in  the  intervals  of  digestion. 

In  cases  of  chronic  hypersecretion,  epigastric  pain  of  the 
same  character  and  periodicity  of  recurrence  is  encountered, 
but  the  most  severe  attack  usually  occurs  at  night  rather  than 
in  the  afternoon  and  frequently  terminates  by  vomiting. 
Dilatation  of  the  stomach  is  as  common  in  this  disease  as  it  is 
exceptional  in  hyperacidity,  the  appetite  is  diminished,  thirst 
is  usually  excessive,  and  the  patient  becomes  greatly  emaciated, 
feeble,  and  despondent.  Exploration  of  the  stomach  with  a 
tube  in  the  early  morning  shows  that  it  contains  a  notable  quan- 
tity of  fluid  rich  in  hydrochloric  acid  and  pepsin,  even  though 
the  organ  had  been  carefully  washed  out  overnight  and  no 
food  had  been  taken  in  the  interval. 

Ulcer  of  the  stomach  is  often  difficult  to  distinguish  from 
primary  hyperacidity,  both  on  account  of  the  similarity  of  its 
symptoms  and  also  from  the  fact  that  it  is  commonly  associated 
with  an  excessive  secretion  of  acid.  It  may  be  noticed, 
however,  that  the  pain  of  a  simple  ulcer  usually  develops 
within  half  an  hour  of  a  meal,  tenderness  on  pressure  is  localised 
strictly  to  the  epigastrium,  while  vomiting  is  comparatively 
frequent  and  affords  immediate  relief.  In  hyperacidity,  on 
the  other  hand,  painful  sensations  are  deferred  for  one  or 
two  hours  after  a  meal,  the  whole  area  of  the  stomach  is  tender, 
and  vomiting  is  never  encountered.     Moreover,  a  continuous 


44  HYPERACIDITY. 

secretion  of  gastric  juice  rather  than  simple  hyperacidity 
usually  accompanies  ulceration  of  the  stomach,  and  con- 
sequently the  organ  is  found  to  contain  the  characteristic  acid 
fluid  both  in  the  early  morning  and  at  other  times  when  it 
should  be  quite  empty.  Haemorrhage  is  a  rare  complication 
of  simple  hyperacidity,  and  when  it  does  occur  the  loss  of  blood 
is  slight,  while  that  which  ensues  from  true  ulceration  is 
always  copious  and  is  followed  by  melaena. 

Biliary  colic  may  easily  be  confused  with  the  painful 
crises  of  hyperacidity,  since  in  both  complaints  the  symptoms 
and  signs  of  hyperacidity  exist  and  the  pain  and  tenderness 
are  situated  in  the  region  of  the  gall-bladder.  Biliary  colic, 
however,  rarely  exhibits  the  periodicity  of  recurrence  met  with 
in  hyperacidity,  and  its  incidence  is  not  confined  to  the  periods 
of  gastric  digestion.  Its  onset  is  more  sudden,  its  character 
more  severe,  and  its  duration  longer  than  the  pain  of  the  func- 
tional complaint,  while  in  many  instances  the  supervention  of 
jaundice  with  enlargement  and  tenderness  of  the  gall-bladder 
affords  an  unmistakable  indication  of  the  nature  of  the  malady. 
The  connection  between  cholelithiasis  and  hypersecretion  will 
be  discussed  in  the  next  chapter. 

Hyperesthesia  of  the  stomach  is  accompanied  by  severe 
pain  after  food  and  also  occasionally  by  hyperacidity.  The 
subjects  of  this  complaint,  however,  are  usually  young  and 
anaemic  women;  the  pain  ensues  immediately  after  a  meal 
and  is  never  deferred  for  more  than  half  an  hour;  vomiting 
is  a  frequent  symptom,  but  only  partially  relieves  the  pain, 
and  little  or  no  relief  is  afforded  by  a  milk  diet.  The  adminis- 
tration of  bicarbonate  of  sodium  has  no  effect,  while  recourse 
to  more  food  increases  rather  than  diminishes  the  trouble. 
On  the  other  hand,  full  doses  of  iron  with  a  suitable  aperient 
soon  remove  the  hyperaesthetic  condition  of  the  gastric  mu- 
cosa; while  similar  treatment  in  a  case  of  hyperacidity 
usually  increases  the  pain  and  excites  vomiting.  Attacks  of 
gastralgia  sometimes  occur  in  the  subjects  of  hysteria  and 


TREATMENT.  45 

neurasthenia,  and  if  associated  with  flatulence  and  other 
symptoms  of  indigestion  may  be  mistaken  for  the  painful 
crises  of  hyperacidity.  As  a  rule,  however,  true  gastralgia 
develops  independently  of  food,  is  much  more  severe,  less 
easily  relieved,  and  is  not  accompanied  by  tenderness  of  the 
abdomen,  while  the  gastric  secretion  never  exhibits  any  decided 
increase  of  free  hydrochloric  acid.  The  "gastric  crises"  of 
locomotor  ataxia  are  occasionally  accompanied  by  the  vomiting 
of  a  hyperacid  fluid,  but  the  absence  of  the  knee-jerks,  and 
the  existence  of  the  usual  signs  of  the  spinal  complaint  are 
sufficient  to  indicate  the  cause  of  the  gastric  phenomena. 

Treatment. — General.  —  The  first  object  in  the  treat- 
ment of  the  disease  is  to  avoid  everything  which  tends  to 
excite  the  glandular  activity  of  the  stomach.  If  the  hyper- 
acidity appears  to  arise  from  mental  exertion,  emotional 
excitement,  or  physical  overstrain,  these  conditions  must  be 
obviated  as  far  as  possible.  During  an  acute  access  of  the 
malady  complete  rest  should  be  enforced,  and  the  patient 
should  remain  in  bed  or  on  a  sofa  for  a  few  days.  Chmate 
always  exercises  an  important  influence  upon  the  severity  of 
the  symptoms,  and  in  many  cases  exposure  to  cold  or  damp 
will  invariably  provoke  an  attack.  Residence  in  an  enervating 
atmosphere  usually  increases  the  disorder,  and  hence  all  low- 
lying  districts,  the  Isle  of  Wight,  Devonshire,  and  the  south- 
west of  England,  are  unsuitable  for  persons  affected  with 
chronic  hyperacidity.  As  a  rule,  inland  health  resorts  are 
preferable  to  those  situated  on  the  coast,  and  especially 
Malvern,  Ilkley,  Hindhead,  the  north  of  Scotland,  and  the 
elevated  parts  of  Sussex  and  Bucks.  In  all  cases  the  patient 
should  be  advised  to  wear  warm  underclothing,  with  a  woollen 
or  chamois-leather  belt  next  the  skin,  and  should  be  warned 
against  the  use  of  cold  baths  in  the  winter  or  prolonged 
immersion  in  the  sea. 

Everything  which  tends  to  increase  the  secretion  of  hydro- 
chloric acid  must  be  avoided,  and  if  the  teeth  are  in  bad  con- 


46    ■  HYPERACIDITY. 

dition  they  should  receive  immediate  attention.  Nuts,  fruits, 
salads,  and  other  substances  diflScult  of  solution  by  the  gastric 
juice  must  be  prohibited,  as  well  as  such  stimulating  articles 
as  pepper,  mustard,  vinegar,  horseradish,  alcoholic  beverages, 
and  beer.  Tea  always  increases  the  acidity,  and  coffee  is 
inadvisable  in  the  majority  of  cases.  Moderate  smoking  need 
not  be  prohibited,  but  strong  tobacco  as  well  as  cigars  must 
be  avoided,  and  the  habit  should  never  be  indulged  in  when 
the  stomach  is  empty. 

Diet. — The  chemistry  of  digestion  in  hyperchlorhydria  dem- 
onstrates in  an  unmistakable  manner  that,  while  nitrogenous 
foods  are  rapidly  dissolved  and  passed  into  the  intestine, 
starches,  and  in  many  cases  fats,  lie  stagnant  in  the  stomach 
and  undergo  fermentation.  Pawlow  has  also  shown  by  ex- 
periment that  the  different  forms  of  proteid  food  excite  varying 
degrees  of  acidity,  the  most  potent  in  this  respect  being  beef 
and  mutton,  while  milk  not  only  induces  the  least  secretion, 
but  also  fixes  the  greatest  proportion  of  free  hydrochloric  acid. 
Lastly,  clinical  experience  teaches  that  starchy  substances 
give  rise  to  more  discomfort  than  proteids,  and  milk  to  less 
than  meat.  In  every  case,  therefore,  milk  should  constitute 
the  staple  diet  during  an  acute  attack  of  the  disorder,"'care 
being  taken  to  administer  it  in  such  form  as  will  prove  most 
agreeable  and  beneficial  to  the  patient.  At  first,  six  ounces  of 
warm  milk  containing  a  tablespoonful  of  lime-water  should  be 
given  every  two  hours,  and  after  a  few  days  the  dose  may  be 
increased  to  half  a  pint  or  more  every  two  and  a  half  hours. 
Some  patients  prefer  the  milk  to  be  mixed  with  Vichy  water 
or  soda  water,  while  others  find  that  the  addition  of  15  grains 
of  citrate  of  sodium  to  each  half-pint  prevents  the  discomfort 
that  sometimes  ensues  from  its  rapid  coagulation  in  the  stomach. 
Peptonization  is,  of  course,  unnecessary,  and  milk  curdled  by 
means  of  lactobacilline  never  agrees.  In  exceptional  cases 
it  may  be  advisable  to  restrict  the  patient  entirely  to  whey 
until  the  irritability  of  the  stomach  has  subsided.     Junket 


TREATMENT.  47 

and  koumiss  answer  very  well  in  some  instances.  As  soon  as 
the  acute  symptoms  have  subsided,  the  milk  may  be  thickened 
with  fine  oatmeal,  sago,  or  ground  rice,  after  which  poached 
and  boiled  eggs,  chicken  cream,  Ipoiled  fish  rubbed  through  a 
sieve,  and  cold  boiled  bacon  may  be  allowed.  Wheaten  bread 
and  toast  always  give  rise  to  discomfort  and  should  be  replaced 
by  rusks  or  the  Brusson- Jeune  rolls.  Sole,  whiting,  plaice, 
and  cod  usually  agree  better  than  the  more  oily  forms  of  fish, 
and  should  be  well  boiled,  finely  minced,  and  served  with  plain 
sauce.  Subsequently,  poultry,  game,  the  various  red  meats, 
tongue,  sweetbreads,  tripe,  and  ham  may  be  allowed,  with  a 
small  quantity  of  boiled  or  mashed  potato,  cauliflower,  or 
seakale  or  asparagus.  On  the  other  hand,  cabbage,  lettuce, 
peas,  beans,  celery,  carrots,  and  turnips  never  agree,  and  no 
fruit  or  nuts  should  be  permitted. 

Although  starchy  foods  tend  to  increase  the  secretion  of 
hydrochloric  acid,  the  soluble  sugars  do  not  appear  to  do  so, 
and,  according  to  Strauss,  a  considerable  amount  of  dextrose 
in  solution  may  be  given  each  day  without  producing  any 
disturbance  of  the  digestion,  provided  that  the  motor  power 
of  the  stomach  is  perfect. 

A  moderate  amount  of  fat  may  be  included  in  the  dietary, 
especially  in  the  form  of  butter  and  cream,  but  fried  bacon  is 
apt  to  give  rise  to  acidity.  Salt  should  be  avoided  as  far  as 
possible. 

The  frequency  of  the  meals  must  vary  in  different  cases. 
If  the  appetite  is  normal  it  is  advisable  to  allow  only  three  full 
meals  during  the  course  of  the  day,  so  as  to  give  the  stomach 
definite  periods  of  rest;  but  when  hunger  is  a  marked  feature 
of  the  case  or  the  patient  finds  that  his  desire  for  food  is  easily 
satisfied,  it  is  better  to  administer  a  smaller  quantity  of  food 
every  three  hours. 

A  moderate  amount  of  fluid  may  be  taken  at  the  end  of  a 
meal  as  it  helps  to  dilute  the  acid  secretion,  and  for  this  purpose 
warm  water,  or  water  containing  bicarbonate  of  potassium  in 


48  HYPERACIDITY. 

the  proportion  of  i  grain  to  the  ounce  is  particularly  valuable, 
or  one  of  the  natural  alkaline  waters,  such  as  those  of  Vichy, 
Ems,  Selt2:er,  or  Contrexeville,  either  alone  or  mixed  with 
milk,  may  be  prescribed.  Kefir  sometimes  agrees  well,  and 
cider  has  been  recommended  by  some  authorities,  but,  as  a  rule, 
acid  fluids  tend  to  increase  the  pain  and  discomfort.  Spirits 
and  beers  always  augment  the  acidity,  but  if  it  is  necessary 
to  administer  alcohol  a  light  white  wine  well  diluted  with  water 
is  perhaps  less  harmful  than  the  other  varieties  of  stimulants. 

Medicinal. — In  mild  cases  or  at  the  commencement  of 
an  attack  the  patient  may  be  directed  to  suck  two  or  three 
compound  bismuth  lozenges  after  meals  or  to  swallow  three  of 
the  5-grain  tabloids  of  bicarbonate  of  sodium.  As  a  rule, 
however,  a  more  active  course  of  treatment  is  required  in  which 
the  exhibition  of  alkahes  plays  the  most  important  part. 
The  majority  of  practitioners  prefer  the  bicarbonate  of  sodium 
either  alone  or  in  combination  with  calcined  magnesia,  but 
some  employ  the  solution  of  potash,  biborate  of  sodium,  or 
prepared  chalk  to  neutraUse  the  excess  of  acid  in  the  stomach. 
Whichever  drug  is  used,  it  should  be  given  in  full  doses  about 
two  hours  after  a  meal.  In  severe  cases  a  sedative  is  always 
required  and  10  minims  of  the  solution  of  morphine  or  a  grain 
of  the  phosphate  of  codeine  may  be  added  to  the  alkahne 
mixture.  Belladonna  has  been  recommended  on  account 
of  its  supposititious  inhibitive  influence  upon  the  gastric 
secretion  (Penzoldt),  but  neither  it  nor  atropine  really  diminish 
the  acidity  and  not  infrequently  induce  vomiting. 

When  the  pain  is  severe  and  only  partially  reheved  by 
alkalies,  it  is  safe  to  assume  that  the  symptom  is  due  in  great 
part  to  a  hyperaesthesia  of  the  gastric  mucous  membrane 
induced  by  long-continued  irritation  by  free  hydrochloric 
acid,  and  under  these  circumstances  the  salts  of  bismuth  are 
invaluable.  As  a  rule,  the  carbonate,  in  doses  of  15  to 
20  grains,  is  the  best  preparation,  especially  when  com- 
bined with  morphine  and  glycerin,  but  the  solution  of  bismuth 


HYPERSECRETION.  49 

prescribed  with  the  elixir  of  chloretone  is  often  of  considerable 
value.  In  very  obstinate  cases  nitrate  of  silver  has  been 
recommended  either  in  the  form  of  a  pill  or  as  a  gastric  douche 
(i:iooo),  but  I  have  never  known  a  case  in  which  any  per- 
manent benefit  was  derived  from  the  employment  of  this  salt. 

The  constipation  which  almost  invariably  accompanies 
hyperacidity  should  be  combated  in  the  first  instance  by  saline 
aperients  administered  in  the  early  morning.  Phosphate  of 
sodium  (2  drachms),  the  artificial  Carlsbad  salts  (2  to  4 
drachms),  sulphate  of  sodium  (2  drachms),  or  Rochelle  salt 
(2  to  4  drachms)  may  be  given  dissolved  in  a  tumblerful  of  hot 
water,  or  recourse  may  be  had  to  such  natural  mineral  waters 
as  those  of  Carlsbad,  Friedrichshall,  Hunyadi  Janos,  or  Apenta. 
As  the  case  improves  the  quantity  is  gradually  reduced  and 
finally  the  saline  is  omitted  in  favour  of  an  occasional  dose  of 
aloes  and  rhubarb,  mercury  and  colocynth,  or  some  other 
simple  aperient. 

Lavage  is  indicated  only  when  gastrectasis  complicates 
the  functional  disorder.  Some  writers  assert  that  internal 
galvanisation  of  the  stomach  reduces  the  secretion  of  hydro- 
chloric acid  and  is  capable  of  curing  the  complaint.  That  the 
acidity  does  occasionally  diminish  under  this  method  of  treat- 
ment cannot  be  doubted,  but  I  have  never  met  with  a  case  in 
which  a  genuine  cure  has  been  effected  by  means  of  electricity. 
Hot-air  baths  have  been  recommended  by  Simon  as  a  means 
of  controlling  the  hyperacidity,  and  considerable  relief  is  often 
experienced  after  copious  perspiration  has  taken  place,  but 
unfortunately  the  improvement  is  only  temporary  and  the 
symptoms  reappear  after  a  few  hours. 

2.  HYPERSECRETION. 

(Synonyms — Continuous    Secretion   of   Gastric  Juice;    Gas- 
trosuccorrhoea;  Disease  of  Reichmann.) 
The   disorder   of   digestion   which    is   commonly   termed 
"hypersecretion"   is  distinguished    from  all   other  forms  of 
4 


50  ACUTE    OR   INTERMITTENT  HYPERSECRETION. 

dyspepsia  by  the  fact  that  the  secretion  of  gastric  juice 
occurs  in  the  intervals  as  well  as  during  the  periods  of  gastric 
digestion,  and  is  therefore  practically  continuous.  This  morbid 
condition  is  usually  regarded  as  a  permanent  one,  and  it  is 
consequently  taught  that,  like  other  chronic  diseases,  it  always 
commences  in  an  insidious  manner  and  pursues  an  uninter- 
rupted course.  Many  observations,  however,  have  been 
recorded  which  tend  to  prove  that  a  continuous  secretion  of 
gastric  juice  may  occur  at  irregular  intervals  and  persist  for  a 
comparatively  short  time,  while  the  chronic  disorder  itself 
not  infrequently  develops  as  a  sequela  of  this  paroxysmal 
form  of  the  complaint.  It  is  therefore  convenient  to  recognise 
two  clinical  varieties  of  hypersecretion,  namely,  the  inter- 
mittent and  the  chronic. 

Acute  or  Intermittent  Hypersecretion. 

Very  little  is  known  concerning  the  etiology  of  this  com- 
plaint. According  to  Reichmann,  it  is  chiefly  encountered  in 
young  persons  of  a  nervous,  active,  and  excitable  disposition, 
and  especially  in  such  as  have  inherited  a  tendency  to  some 
neurosis.  The  disorder,  however,  may  appear  at  any  age  and 
may  recur  until  an  advanced  period  of  life.  Over-excitement 
and  cerebral  fatigue  often  appear  to  be  responsible  for  an 
attack,  while  in  not  a  few  instances  an  unusually  heavy  meal 
or  the  ingestion  of  some  special  article  of  diet  is  followed 
immediately  by  the  symptoms  of  the  complaint.  Thus,  in 
certain  individuals,  a  draught  of  iced  beer  or  water,  a  strong 
cigar,  or  indulgence  in  smoked  fish,  bacon,  calf's  liver,  cider, 
spirits,  or  stone  fruit  are  particularly  injurious,  while  in  others 
some  temporary  indisposition,  such  as  influenza,  tonsillitis, 
a  bout  of  intemperance,  or  even  a  severe  chill,  is  sufficient  to 
provoke  a  seizure.  Some  writers  have  asserted  that  the 
gastric  crises  of  locomotor  ataxia  are  due  to  intermittent 
hypersecretion,  and  Sahli  has  reported  an  instance  in  which 


SYMPTOMS.  51 

the  two  conditions  appeared  to  be  intimately  connected;  but, 
as  a  rule,  no  evidence  of  a  continuous  secretion  of  gastric  juice 
can  be  demonstrated  during  the  course  of  the  spinal  complaint. 
On  the  other  hand,  in  certain  cases  of  cerebral  tumor  the 
locahsing  symptoms  of  the  lesion  may  be  preceded  for  several 
months  by  recurrent  attacks  of  hypersecretion,  accompanied 
by  violent  headache,  which  are  very  apt  to  be  mistaken  for 
seizures  of  the  so-called  "bihous"  type  and  thus  to  lead  to  a 
serious  error  of  diagnosis.  In  the  female  an  attack  of  hyper- 
secretion sometimes  precedes  or  follows  the  menstrual  periods, 
especially  if  there  be  dysmenorrhoea  or  disease  of  the  ovaries 
or  appendages.  Personally,  I  believe  that  intermittent 
hypersecretion  is  merely  an  early  phase  of  the  chronic  disorder 
and  is  always  due  to  an  organic  lesion  of  the  digestive  organs. 
In  three  cases  of  this  description  that  were  submitted  to 
operation  after  suffering  from  two  attacks,  each  of  about  a 
fortnight's  duration,  a  chronic  ulcer  of  the  duodenum  was 
found  to  exist. 

Symptoms. — An  attack  usually  develops  quite  suddenly 
during  a  period  of  apparently  good  health.  In  the  early 
hours  of  the  morning  the  patient's  rest  is  disturbed  by  dreams, 
and  he  awakes  with  a  sense  of  ill-defined  discomfort  or  a  feeling 
of  oppression  at  the  chest.  Within  a  short  time  the  disturbance 
becomes  localised  to  the  upper  part  of  the  abdomen,  which 
grows  distended  and  tender;  belching  of  gas  and  regurgi- 
tations of  an  acid  fluid  are  followed  by  a  severe  and  often 
spasmodic  form  of  pain,  and  finally  vomiting  ensues  which 
affords  relief. 

At  first  the  ejecta  consist  of  partially  digested  food,  but 
after  the  emesis  has  been  repeated  once  or  twice  the  material  is 
found  to  be  composed  almost  entirely  of  a  yellow  or  green  sour- 
smelling  fluid,  which  gives  an  acid  reaction  with  Htmus-paper 
and  contains  both  free  hydrochloric  acid  and  the  peptic  fer- 
ment. The  total  acidity  varies  between  40  and  60,  and, 
except  in  the  specimens   which   are   mixed   with   food,   the 


52  ACUTE    OR   INTERMITTENT  HYPERSECRETION. 

percentage  of  free  hydrochloric  acid  rarely  exceeds  the  normal. 
The  vomiting  continues  to  recur  at  intervals,  preceded  by 
severe  nausea,  and  during  the  attack  3  pints  or  more  of 
bile-stained  gastric  juice  may  be  rejected,  although  neither 
food  nor  liquid  has  been  introduced  into  the  stomach. 
Mucus  is  usually  present  in  moderate  quantity,  and  occasion- 
ally a  coffee-ground  appearance  of  the  vomit  indicates  the 
existence  of  shght  gastric  haemorrhage.  Great  thirst  is  ex- 
perienced during  the  attack,  but  draughts  of  water  almost 
always  excite  nausea  and  vomiting.  The  appetite  is  com- 
pletely lost,  the  pulse  is  small  and  quick,  and  the  temperature 
of  the  body  is  depressed.  Constipation  is  invariably  present. 
In  many  instances  great  restlessness  is  exhibited,  and  the 
patient  continually  tosses  about  in  his  bed,  and  may  even 
exhibit  shght  dehrium.  In  certain  cases,  and  especially  in 
young  people,  the  attack  is  ushered  in  by  severe  headache, 
which  is  increased  by  any  movement  of  the  body  and  is  only 
reheved  by  the  vomiting  of  the  acid  contents  of  the  stomach. 
Photophobia,  with  congestion  of  the  conjunctivae  and  lachry- 
mation,  and  even  transient  diplopia,  may  occur  at  the  com- 
mencement of  the  disease.  A  condition  very  similar  in  its 
general  characters  to  this  was  described  by  Rossbach  in  1884 
under  the  title  of  "  Gastroxnysis" ;  by  Lepine  in  1885  by  that 
of  ''  Gastroxie";  by  Rosenthal  in  1887,  and  by  the  writer  in  his 
work  on  Disorders  of  Digestion  in  Childhood,  under  the  term 
"Paroxysmal  Hyperacidity."  In  all  these  cases  the  cephal- 
algia appears  to  be  directly  connected  with  the  excessive 
secretion  of  acid,  since  it  is  immediately  relieved  when  the 
gastric  contents  are  neutralised  by  the  introduction  of  an 
alkali  or  removed  by  evacuation  of  the  stomach. 

During  the  early  stages  of  the  disorder  the  tongue  is  moist 
and  red;  but  it  soon  becomes  covered  with  a  creamy- white 
fur,  and  in  severe  cases  may  eventually  be  dry,  brown,  and 
cracked.  The  urine  is  greatly  reduced  in  amount  and 
presents  an  abnormally  high  colour.     The  output  of  chlorides 


SYMPTOMS.  53 

is  greatly  diminished  owing  to  the  enforced  abstinence  from 
food  and  the  vomiting  of  large  quantities  of  hydrochloric  acid. 
The  excretion  of  urea  is  also  notably  diminished.  Occasion- 
ally the  urine  presents  a  peculiar  glistening  appearance  owing 
to  the  presence  of  a  vast  number  of  uric  acid  crystals,  and  this 
phenomenon  usually  indicates  the  proximity  of  the  crisis. 
During  the  attack  a  loss  of  weight  varying  from  3  to  9  lb. 
usually  occurs. 

The  duration  of  the  attack  varies  considerably  in  different 
cases,  in  some  the  symptoms  only  lasting  for  a  few  hours,  while 
in  others  they  endure  for  several  weeks  with  occasional  remis- 
sions. As  a  rule,  the  shorter  seizures  are  accompanied  by  the 
most  severe  symptoms,  while  in  the  more  prolonged  cases 
severe  pain  is  only  experienced  at  intervals  immediately  prior 
to  vomiting,  and  is  relieved  as  soon  as  the  stomach  has  been 
evacuated.  The  pain  itself  is  chiefly  referred  to  the  region 
of  the  pylorus,  whence  it  radiates  over  the  abdomen,  chest,  and 
back.  Its  sudden  cessation  is  often  accompanied  by  gurgling 
and  by  the  feeling  that  an  internal  spasm  has  suddenly  relaxed, 
while  its  more  gradual  subsidence  is  frequently  attended  by 
the  expulsion  of  gas  by  the  bowel  or  polyuria.  Occasionally 
the  gastric  intolerance  becomes  complete,  when  not  only  is 
every  effort  to  partake  of  food  followed  by  vomiting,  but  any 
movement  of  the  body  induces  painful  retching  and  the 
patient  experiences  constant  nausea,  giddiness,  and  faintness. 
The  abdomen  is  somewhat  retracted,  and  pressure  upon  the 
epigastrium  gives  rise  to  pain. 

As  soon  as  the  vomiting  ceases  and  the  patient  is  able  once 
more  to  take  nourishment  by  the  mouth,  he  rapidly  improves 
in  health  and  soon  regains  the  weight  that  he  had  lost. 
Between  the  attacks  he  usually  presents  a  healthy  appearance 
and  declares  that  he  is  perfectly  well.  Careful  examination, 
however,  will  show  that  the  stomach  contains  a  small  quantity 
of  acid  secretion  in  the  early  morning,  while  after  a  test  meal 
the  gastric  contents  are  unduly  liquid  and  possess  an  excess 


54  ACUTE    OR  INTERMITTENT  HYPERSECRETION. 

of  free  hydrochloric  acid.  In  other  words,  a  mild  form  of 
chronic  hypersecretion  exists  without  noticeable  symptoms. 

The  most  interesting  sequela  of  an  attack  of  acute  hyper- 
secretion is  the  supervention  of  jaundice.  When  this  occurs 
the  gastric  symptoms  rarely  persist  for  more  than  two  or  three 
days,  and  it  is  not  until  the  vomiting  has  subsided  that  the 
skin  and  conjunctivae  exhibit  an  icteric  tinge.  The  urine  is 
loaded  with  bile  pigment,  the  stools  are  clay-coloured,  and 
great  apathy  and  depression  are  complained  of.  This  con- 
dition may  last  for  several  days  and  is  apt  to  recur  after  each 
subsequent  attack  of  the  gastric  disorder.  It  appears  to  be 
due  to  the  irritant  effect  of  the  hyperacid  gastric  contents  upon 
the  duodenal  mucous  membrane,  which  induces  a  mild  attack 
of  duodenitis  with  resultant  obstruction  of  the  bile  duct  and 
probably  also  of  the  pancreatic  duct.  Frequent  attacks  of 
acute  hypersecretion  invariably  give  rise  to  dilatation  of  the 
stomach,  with  chronic  inflammation  of  its  mucous  membrane, 
and  in  the  great  majority  of  the  cases  chronic  hypersecretion 
eventually  supervenes.  The  occasional  occurrence  of  mild 
hsematemesis  from  erosions  of  the  gastric  mucosa  has  already 
been  mentioned. 

Diagnosis. — The  general  similarity  that  exists  between 
the  symptoms  of  acute  hypersecretion,  acute  gastritis,  and 
migraine  render  it  impossible  to  diagnose  the  complaint 
merely  from  a  patient's  description  of  an  attack.  An  ex- 
amination of  the  vomit,  on  the  other  hand,  always  provides 
important  results.  Thus,  if  the  ejecta  are  found  to  consist 
of  gastric  juice  containing  both  free  hydrochloric  acid  and 
pepsin,  and  if  large  quantities  of  this  fluid  are  vomited  from 
time  to  time  without  the  introduction  of  any  food  into  the 
stomach,  the  diagnosis  of  hypersecretion  is  at  once  established. 
Furthermore,  if,  after  the  subsidence  of  the  acute  symptoms, 
exploration  of  the  stomach  in  the  early  morning  proves  the 
viscus  to  be  empty,  there  can  be  little  doubt  that  the  continuous 
secretion  of  gastric  juice  was  not  of  a  permanent  character. 


TREATMENT.  55 

An  attack  of  acute  gastritis  is  usually  characterised  by  epigas- 
tric discomfort  rather  than  pain,  headache  is  absent  or  of  a  mild 
type,  and  the  vomit  consists  of  alkaline  and  bile-stained  mucus. 

In  cases  of  migraine  the  vomiting,  like  that  of  hyper- 
secretion, usually  affords  relief  to  the  other  sym.ptoms;  but  in 
this  disorder  severe  headache  is  the  predominant  symptom, 
while  the  ejecta  are  small  in  quantity,  alkaline  in  reaction,  and 
consist  entirely  of  mucus  mixed  with  a  variable  amount  of  yellow 
bile.  Epigastric  pain  is  absent,  the  attacks  occur  at  frequent  in- 
tervals, but  rarely  last  more  than  forty-eight  hours,  and  a  family 
predisposition  to  the  complaint  can  usually  be  determined. 

In  those  rare  cases  of  locomotor  ataxia  in  which  hyper- 
secretion occurs  with  the  gastric  crises,  the  sex  and  age  of  the 
patient  combined  with  the  physical  signs  of  spinal  lesion  are 
sufficient  to  indicate  the  true  nature  of  the  malady. 

Treatment. — (i)  During  the  Attack. — In  all  cases  the 
patient  should  be  confined  to  bed  as  long  as  pain  or  vomiting 
persists.  No  food  should  be  allowed  by  the  mouth,  but  a 
little  ice  may  be  sucked  if  thirst  is  severe,  or  the  patient  may 
be  encouraged  to  rinse  out  his  mouth  at  intervals  with  hot 
water.  If  the  vomiting  persists  for  more  than  twenty-four 
hours,  from  15  to  20  oz.  of  warm  peptonised  milk  should 
be  slowly  introduced  into  the  rectum  through  a  tube  every 
six  hours,  and  the  bowel  be  washed  out  with  a  weak  solution 
of  common  salt  every  morning.  In  this  manner  all  irritation 
of  the  stomach  by  the  ingestion  of  food  is  avoided,  and  the 
duration  of  the  attack  is  much  curtailed.  Some  authorities 
prefer,  however,  to  administer  food  by  the  mouth  during  the 
whole  period,  and  for  this  purpose  recommend  milk  mixed 
with  Vichy  or  lime-water,  white  of  egg,  or  hard-boiled  eggs. 

The  quickest  method  of  reheving  the  pain  and  sickness  is 
to  introduce  a  soft  tube  into  the  stomach,  and  after  evacuating 
the  organ  of  its  acid  contents,  to  thoroughly  wash  it  out  with  a 
weak  solution  of  bicarbonate  of  sodium  (2  grains  to  the  ounce). 
Some  writers  recommend  a  solution  of  nitrate  of  silver  (i  in 


56  CHRONIC  HYPERSECRETION, 

i,ooo)  with  the  view  of  controlling  the  secretion  of  gastric 
juice,  but  this  treatment  is  rarely  of  any  value  and  is  very 
apt  to  excite  pain.  When  the  retching  and  vomiting  are 
extremely  severe,  it  is  a  good  plan  to  introduce  through  the 
tube  a  drachm  of  the  carbonate  of  bismuth  suspended  in  6  oz. 
of  water  at  the  completion  of  the  lavage  and  to  leave  it  in  the 
stomach.  As  a  rule,  the  lavage  should  be  repeated  every  six 
hours,  but  it  is  seldom  required  more  than  four  times  during 
the  attack.  If  the  tube  cannot  be  employed  excessive  pain 
may  be  controlled  by  an  hypodermic  injection  of  morphine, 
while  a  mixture  containing  bicarbonate  of  sodium  or  liquor 
potassEe  combined  with  carbonate  of  bismuth  and  calcined 
magnesia  should  be  administered  every  two  hours  with  the 
object  of  neutralising  the  excessive  acidity  of  the  gastric 
contents.  As  soon  as  the  vomiting  has  subsided  milk  and 
lime-water  and  eggs  may  be  allowed,  and  within  a  short  time 
the  patient  will  be  able  to  resume  his  ordinary  diet. 

(2)  Between  the  attacks  an  effort  should  be  made  to  remove 
the  cause  of  the  complaint.  With  this  object  the  contents  of 
the  stomach  should  be  examined  after  a  test  meal,  when  the 
existence  of  hyperacidity  can  easily  be  determined.  If  it  can 
be  shown  by  the  incidence  of  the  attacks  that  mental  or 
physical  overstrain  is  an  important  factor  in  their  causation, 
the  patient  must  be  advised  to  limit  his  labours  and  to  take 
regular  exercise  in  the  fresh  air.  Excessive  smoking  must 
always  be  prohibited,  and  in  severe  cases  the  habit  should  be 
entirely  abandoned.  Alcohol  rarely  agrees,  and  in  many  cases 
an  attack  can  be  traced  to  indulgence  in  even  a  small  quantity 
of  wine  or  spirits.  In  neurasthenic  and  hysterical  subjects 
the  treatment  should  be  directed  to  the  cure  of  the  nervous 
complaint. 

CHRONIC  HYPERSECRETION. 

Etiology. — ^Various  statements  have  been  made  concerning 
the  frequency  of  chronic  hypersecretion,  some  writers  pro- 
nouncing it  to  be  a  common  complaint,  while  others  consider 


ETIOLOGY.  57 

it  a  rare  one.  Among  my  five  hundred  cases  of  dyspepsia 
treated  in  hospital  there  were  twenty-five  examples  of  this 
disorder  (5  per  cent.),  while  among  those  examined  in  private 
practice  the  percentage  frequency  of  the  complaint  was  32.4. 

The  general  symptoms  of  hypersecretion  appear  to  have 
been  quite  familiar  to  English  physicians  of  the  early  part  of 
last  century,  who  were  wont  to  ascribe  them  to  an  "acid"  or 
"irritative"  dyspepsia,  but  it  was  not  until  the  pubhca- 
tion  of  Reichmann's  researches  in  1882  that  the  association 
of  certain  clinical  phenomena  with  a  continuous  secretion  of 
gastric  juice  was  recognized.  According  to  this  observer, 
chronic  gastrosuccorrhoea  is  a  secretory  perversion  of  nervous 
origin,  and  as  such  it  is  still  regarded  by  the  great  majority  of 
physicians.  On  the  other  hand,  Schreiber  and  those  who 
follow  him  contend  that  the  healthy  stomach  is  never  en- 
tirely empty,  and  that  in  the  early  morning  a  certain  amount 
of  gastric  juice  may  always  be  withdrawn  from  the  organ 
owing  to  the  stimulating  effect  upon  the  secretory  glands  of 
dust,  saliva,  and  mucus  which  are  swallowed  unconsciously  dur- 
ing the  night.  Moreover,  it  is  believed  by  this  school  that  a  con- 
tinuous gastric  secretion  depends  upon  dilatation  of  the  stomach, 
and  that  the  stagnation  of  food  which  ensues  from  gastrectasis 
acts  as  a  constant  stimulant  to  the  mucous  membrane. 

It  is  obvious,  therefore,  that  two  preliminary  questions 
require  to  be  settled  before  the  etiology  of  the  complaint  can  be 
discussed,  namely,  does  a  healthy  stomach  contain  gastric 
juice  in  the  fasting  state,  and  can  simple  gastrectasis,  or 
motor  insufficiency,  induce  hypersecretion. 

With  regard  to  the  first  point,  the  methods  employed  in 
the  earlier  investigations  are  certainly  open  to  criticism.  It 
was  formerly  the  invariable  custom  to  explore  the  stomach 
with  a  soft  tube,  and  then  by  means  of  pressure  applied  over 
the  region  of  the  stomach,  accompanied  by  voluntary  efforts 
of  straining  on  the  part  of  the  patient,  to  squeeze  out  any 
material  that  might  be  contained  in  the  organ.     That  such  a 


58  CHRONIC  HYPERSECRETION. 

procedure  is  ever  capable  of  completely  emptying  a  large 
flaccid  bag  with  a  plicated  inner  lining  must  be  open  to  doubt 
when  it  is  remembered  that  even  the  most  careful  lavage  fails 
to  cleanse  the  stomach  of  minute  particles  of  food,  while 
irritation  of  the  gastric  mucosa  induced  by  the  tube  must  of 
necessity  excite  a  certain  amount  of  secretion.  On  the  other 
hand,  by  the  employment  of  Gentile's  evacuator,  the  stomach 
may  be  completely  emptied  within  thirty  seconds,  during  which 
brief  time  the  tube  cannot  excite  the  secretion  of  more  than  a 
few  drops  of  gastric  juice.  Many  experiments  conducted  in 
this  manner  have  convinced  me  that  when  a  healthy  stomach 
is  carefully  washed  out  and  emptied  by  aspiration  in  the 
evening,  and  no  food  or  drink  is  taken  in  the  interval,  aspir- 
ation on  the  following  morning  never  reveals  more  than  lo  c.c. 
of  an  opalescent  fluid  which  may  or  may  not  give  the  reactions 
of  free  hydrochloric  acid. 

Since  this  conclusion  is  in  complete  accord  with  the  state- 
ments of  Riegel  and  other  modern  writers  who  have  employed 
an  aspirator  instead  of  the  usual  method  of  siphonage,  it 
may  be  accepted  that  the  presence  of  more  than  20  c.c.  of 
gastric  juice  in  the  fasting  stomach  is  of  pathological  import. 

With  regard  to  the  second  question,  namely,  the  supposi- 
titious influence  of  gastrectasis  on  the  causation  of  hypersecre- 
tion, I  would  adduce  the  following  facts:  Primary  gastric 
myasthenia,  or  atony,  is  always  accompanied  by  food  stag- 
nation, and  yet  gastric  juice  in  quantities  exceeding  10  c.c. 
are  never  encountered  in  the  early  morning  even  after  a  full 
meal  has  been  taken  on  the  previous  evening,  while  lavage 
and  aspiration  of  the  stomach  at  night  is  followed  by  the  signs 
of  an  empty  organ  the  next  morning.  Again,  a  mechanical 
obstruction  to  the  exit  of  chyme  into  the  duodenum,  such  as 
results  from  adhesion  of  the  pylorus  or  first  part  of  the  duo- 
denum to  a  hydatid  or  gumma  of  the  liver  is  not  attended 
by  the  signs  of  hypersecretion,  indeed,  subacidity  is  the 
rule  in  such  cases;  while  that  severe  form  of  motor  insuffi- 


ETIOLOGY.  59 

ciency  that  ensues  from  carcinoma  of  the  pylorus  is  accom- 
panied by  a  diminished  rather  than  by  an  excessive  secretion 
of  gastric  juice.  This  latter  statement,  however,  is  by  no 
means  absolute,  since  in  four  cases  that  have  come  under  my 
notice,  a  rapidly  growing  columnar-cell  cancer  of  the  pylorus 
was  accompanied  by  such  evident  hypersecretion  as  to  render 
the  diagnosis  of  malignant  disease  a  matter  of  difficulty. 
In  m.any  cases  of  this  kind  a  simple  ulcer,  gall-stones,  or 
diseased  appendix  attended  by  hypersecretion  had  existed 
previously  to  the  development  of  the  carcinoma;  but  I  am  not 
sure  that  independently  of  these  antecedent  lesions  cancer  of 
the  pylorus  may  not  in  certain  individuals  excite  temporary 
hypersecretion.  With  these  rare  exceptions,  a  continuous 
secretion  of  gastric  juice  never  results  from  motor  insufficiency. 
It  is,  of  course,  well-known  that  hypersecretion  commonly 
accompanies  chronic  ulcer  of  the  stomach,  but  it  is  nevertheless 
the  custom  to  regard  a  continuous  secretion  of  gastric  juice 
as  a  disorder  of  nervous  origin  and  to  attribute  it  to  the  same 
conditions  that  are  supposed  to  excite  simple  hyperacidity. 
Thus,  among  the  supposititious  causes  of  the  disorder,  much 
stress  is  usually  laid  upon  over-indulgence  in  rich  and  highly 
spiced  foods,  the  abuse  of  alcohol  or  tobacco,  inefficient 
mastication,  and  long-continued  mental  strain  or  excitement; 
but  since  these  several  conditions  are  also  held  responsible 
for  other  forms  of  indigestion,  while  their  mere  existence  does 
not  explain  why  they  should  excite  in  one  individual  hyper- 
acidity, in  another  gastritis,  and  in  a  third  hypersecretion,  it 
seems  advisable  to  investigate  the  various  organs  of  the  body 
as  well  as  the  habits  of  the  patient  in  order  to  discover,  if 
possible,  some  reason  for  such  diverse  consequences  of  the 
same  cause.  Until  the  year  1907  I  had  felt  convinced  from 
post-mortem  evidence  as  well  as  from  the  more  limited  results 
afforded  by  operations,  that  88  per  cent,  of  all  cases  of  chronic 
hypersecretion  were  accompanied  by  a  demonstrable  lesion 
of  the  digestive  organs,  while  in  the  remaining  12  per  cent. 


6o  CHRONIC  HYPERSECRETION. 

no  disease  which  appeared  to  have  any  connection  with  the 
stomach,  could  constantly  be  demonstrated.  I  was,  however, 
well  acquainted  with  a  peculiar  type  of  hypersecretion  in 
which  death  frequently  resulted  from  acute  appendicitis,  and 
was  in  the  habit  of  warning  such  patients  of  their  special 
liability  to  this  disease;  but  it  was  not  until  an  opportunity 
occurred  of  discussing  the  subject  with  W.  Mayo,  of  Rochester, 
that  the  cause  of  this  appendicitis  and  also  an  explanation  of 
the  12  per  cent,  of  cases  hitherto  unaccounted  for  at  once 
became  apparent.  That  distinguished  surgeon  informed  me  that 
he  had  often  discovered  latent  disease  of  the  appendix  in 
persons  who  seemed  to  require  gastro-jejunostomy  and  that  the 
removal  of  the  appendix  was  followed  by  the  subsidence  of  the 
gastric  symptoms,  provided  that  the  alimentary  tract  was 
otherwise  healthy.  Furthermore,  that  several  of  his  earlier 
cases  of  gastro-jejunostomy  which  had  not  been  materially 
benefited  by  the  operation  had  subsequently  been  found  to 
possess  disease  of  the  appendix,  and  that  when  this  had  been 
removed  a  cure  had  resulted. 

With  these  facts  in  mind  the  various  surgeons  who  have 
operated  for  me  on  cases  of  hypersecretion  during  the  last 
two  years  have  examined  the  appendix  as  well  as  the  other 
important  abdominal  viscera,  and  the  results  obtained  in 
one  hundred  and  twelve  consecutive  cases  are  as  follows : 

Chronic  ulcer  of  the  stomach  existed  alone  in 
Chronic  duodenal  ulcer  existed  alone  in 
Gall-stones  existed  alone  in 
Diseases  of  the  appendix  existed  alone  in 
Gastric  and  duodenal  ulcers  co-existed  in 
Duodenal  ulcer  and  gall-stones  co-existed  in 
Gastric  ulcer  and  diseased  appendix  co-existed  in 
Duodenal  ulcer  and  diseased  appendix  co-existed  in 
Cancer  of  the  pylorus  existed  alone  in 

Total,  112 


13 

cases 

46 

cases 

12 

cases 

22 

cases 

3 

cases 

3 

cases 

5 

cases 

4 

cases 

4 

cases 

ETIOLOGY.  6l 

Out  of  the  thirteen  examples  of  gastric  ulcer,  the  disease 
occupied  the  cardiac  portion  of  the  viscus  in  four,  the  central 
zone  in  three,  and  the  pyloric  third  in  six;  and  it  is  interesting 
to  observe  that  one  of  the  most  severe  clinical  examples  of 
hypersecretion  was  associated  with  an  ulcer  close  to  the 
cardiac  orifice.  When  gall-stones  constituted  the  sole  indi- 
cation of  disease,  the  calculus  was  often  single  and  completely 
filled  the  gall-bladder,  and  in  only  one  case  was  there  a 
history  of  biliary  colic.  Hsematemesis  or  melaena  was  noted 
in  only  three  out  of  the  forty-six  examples  of  duodenal  ulcer, 
notwithstanding  that  the  average  duration  of  the  symptoms 
of  hypersecretion  prior  to  operation  was  nine  years,  while  in 
several  instances  they  had  existed  more  than  seventeen  years. 
In  only  three  out  of  the  twenty-two  examples  of  diseased 
appendix  was  there  a  history  indicative  of  previous  inflam- 
mation of  the  organ,  although  at  operation  it  was  found  to  be 
either  extensively  ulcerated,  much  thickened,  dilated,  or 
occupied  by  a  calculus.  Finally,  it  may  be  mentioned  that  in 
almost  every  instance  the  removal  of  the  gall-stones  or  diseased 
appendix  or  the  performance  of  gastro-jejunostomy  for  ulcer 
was  followed  by  a  subsidence  of  the  former  symptoms,  and 
Paterson  has  shown  conclusively  that  in  cases  of  ulcer  gastro- 
jejunostomy actually  causes  a  disappearance  of  the  continuous 
gastric  secretion. 

Although  the  number  of  cases  is  comparatively  small,  the 
results  are  sufficiently  definite  to  permit  of  several  conclusions 
being  drawn  from  them. 

In  the  first  place,  it  is  quite  clear  that  chronic  hypersecretion 
is  not  a  disease,  but  merely  an  expression  of  an  organic  lesion 
of  some  part  of  the  digestive  tract  or  of  those  organs  that  pour 
their  secretions  into  it,  and  while  most  cases  may  be  accounted 
for  by  the  presence  of  gall-stones,  gastric  or  duodenal  ulcer, 
or  a  diseased  appendix,  I  believe  further  experience  will  show 
that  pancreatic  calculus,  cancer  and  tubercle  in  the  region 
of  the  csecum  can  also  induce  the  gastric  disorder. 


62  CHRONIC  HYPERSECRETION. 

Secondly,  whatever  be  the  immediate  cause  of  the  hyper- 
secretion, the  continued  existence  of  the  latter  not  only  excites 
inflammation  of  the  stomach  and  duodenum,  but  also  produces 
haemorrhagic  erosions,  which  occasionally  increase  in  size 
and  depth  and  finally  acquire  all  the  characteristic  features 
of  chronic  ulcers.  In  this  manner  both  gastric  and  duodenal 
ulcers  are  apt  to  ensue  from  hypersecretion  due  in  the  first 
instance  to  gall-stones  or  appendicitis,  while  the  chronic 
colitis  that  develops  in  so  many  cases  of  hypersecretion  may 
eventually  lead  to  inflammation  of  the  appendix.  Lastly,  the 
existence  of  hypersecretion  does  not  exclude  the  possibiHty 
of  carcinoma;  on  the  contrary,  it  is  probable  that,  putting  aside 
the  development  of  malignant  disease  in  a  chronic  ulcer,  a 
rapidly  growing  carcinoma  may  of  itself  excite  a  continuous 
secretion  of  gastric  juice;  in  such  cases  the  neoplasm  grows 
with  extraordinary  rapidity,  is  often  accompanied  by  profuse 
haemorrhages,  and  usually  terminates  fatally  within  seven 
months. 

It  is,  of  course,  impossible  to  explain  the  exact  connection 
between  these  various  lesions  and  a  continuous  secretion  of 
gastric  juice,  but  it  is  probable  that  a  reflex  irritation  is 
chiefly  responsible  for  it;  and  in  this  connection  it  is  interest- 
ing to  observe  that  Paterson  has  demonstrated  that  an  in- 
creased acidity  of  the  gastric  contents  almost  invariably 
occurs  after  removal  of  the  appendix.  The  most  profuse 
secretion  is  usually  associated  with  disease  in  the  immedi- 
ate vicinity  of  the  pylorus,  either  on  the  gastric  or  duod- 
enal side,  and  the  highest  degree  of  acidity  is  encountered  in 
cases  where,  owing  either  to  cicatricial  stenosis  or  to  spasm, 
there  is  a  chronic  impediment  to  the  exit  of  chyme  from  the 
stomach.  On  the  other  hand,'  central  stenosis  of  the  stomach 
(hour-glass)  is  very  seldom  accompanied  by  hypersecretion, 
and  free  hydrochloric  acid  is  rarely  found  in  this  condition. 
Simple  strictures  of  the  jejunum  and  ileum  resulting  from  the 
healing  of  tuberculous  ulcers   are  usually  associated  with   a 


SYMPTOMS.  63 

diminution  rather  than  an  excess  of  gastric  secretion,  and 
the  same  may  be  said  of  both  simple  and  mahgnant  strictures 
of  the  large  intestine. 

The  sex  and  age  of  the  patient  varies  according  to  the 
cause  of  the  hypersecretion.  In  my  cases,  the  female  sufferers 
from  gastric  ulcer  exceeded  the  male  in  the  proportion  of 
3  to  I,  while  in  duodenal  ulcers  the  ratio  of  men  to  women 
was  2 . 5  to  I .  The  average  age  at  the  time  of  operation  in  both 
instances  being  about  forty-one  years.  Hypersecretion  due  to 
gall-stones  appears  to  be  rather  more  frequent  in  women,  while 
in  that  which  ensues  from  appendicitis  both  sexes  are  equally 
affected. 

Symptoms. — In  the  majority  of  cases  the  disorder  com- 
mences in  an  insidious  manner  with  the  symptoms  of  chronic 
hyperacidity  associated  with  recurrent  attacks  of  acute  hyper- 
secretion, and  it  is  only  after  the  lapse  of  many  months  or 
even  years  that  the  phenomena  characteristic  of  continuous 
secretion  manifest  themselves.  In  other  instances  the  com- 
plaint commences  abruptly  when  the  patient  is  apparently  in 
good  health  and  is  attributed  by  him  to  exposure  to  cold,  an 
indiscretion  in  diet,  indulgence  in  iced  water,  beer,  or  stimulants, 
severe  excitement,  or  to  an  attack  of  influenza  or  other  febrile 
malady.  In  these  latter  cases  the  gastric  symptoms  either 
subside  after  a  week  or  two  to  recur  again  and  again  at  short 
intervals,  or  they  gradually  assume  a  chronic  form  without 
exhibiting  any  decided  intermission. 

Pain  in  one  form  or  another  is  invariably  present  and 
closely  resembles  that  which  ensues  from  simple  hyperacidity. 
Thus,  it  usually  commences  by  a  sensation  of  fulness,  un- 
easiness, or  burning  at  the  epigastrium  one  or  two  hours  after 
each  meal,  and  at  the  crisis  of  the  attack  may  be  so  severe  as 
to  resemble  biliary  colic.  This  type  presents  three  peculiar 
features  which  serve  to  distinguish  it  from  the  pain  of  other 
forms  of  dyspepsia.  '  In  the  first  place,  it  is  particularly  apt  to 
develop  before  a  meal,  and  if  accompanied  by  a  curious  sense 


64  CHRONIC  HYPERSECRETION. 

of  emptiness  and  sinking  at  the  pit  of  the  stomach  is  some- 
times referred  to  as  "hunger  pain."  The  long  interval  that 
elapses  in  such  cases  between  the  ingestion  of  food  and  the 
development  of  the  pain  usually  indicates  that  the  stomach  is 
able  to  evacuate  its  contents  into  the  intestine  without  trouble, 
but  that  the  subsequent  accumulation  of  a  hyperacid  gastric 
juice  induces  a  painful  spasm  of  the  muscular  coat  of  the 
viscus  and  of  the  pyloric  sphincter.  Some  writers  have  tried  to 
convince  themselves  that  that "  hunger  pain"  is  pathognomonic 
of  duodenal  ulcer,  whereas,  of  course,  it  is  merely  symptomatic 
of  severe  hypersecretion  of  which  ulcer  of  the  duodenum  is  a 
common,  but  by  no  means  the  sole  cause.  I  have  observed  very 
well-marked  instances  of  this  form  of  pain  in  ulcer  of  the  stom- 
ach near  the  cardiac  orifice,  as  well  as  in  the  centre  of  the  viscus 
and  close  to  the  pylorus,  and  also  in  gall-stones  and  ulceration  of 
the  appendix,  and  the  only  distinction  I  have  been  able  to  draw 
was  that  the  symptom  was  most  severe  when  the  ulcer  occupied 
the  vicinity  of  the  pylorus.  The  second  important  feature  of 
the  pain  is  the  relief  that  is  immediately  afforded  by  the 
ingestion  of  proteid  foods,  such  as  milk,  albumin  water,  meat 
essence,  biscuits,  etc.  This  peculiarity  is  due  to  the  strong 
chemical  affinity  that  exists  between  albumin  and  hydro- 
chloric acid  in  a  free  state,  which  results  in  the  formation  of  a 
compound  possessed  of  considerable  stability  and  yet  devoid 
of  the  irritant  and  digestive  properties  of  the  free  mineral 
acid. 

Thirdly,  nocturnal  attacks  of  pain,  while  rarely  met  with  in 
simple  hyperacidity  or  other  varieties  of  dyspepsia,  are  almost 
invariable  in  hypersecretion,  especially  when  it  depends  upon 
gastric  or  duodenal  ulcer;  and  since  they  occur  at  a  time 
when  the  stomach  is  partially  devoid  of  food,  they  are  usually 
experienced  between  i  and  3  o'clock  in  the  morning.  The 
later  the  hour  at  which  the  last  meal  is  taken  the  later  will  be 
the  onset  of  the  pain  and,  consequently,  those  individuals  who 
habitually  indulge  in  a  supper  near  midnight  often  remain 


SYMPTOMS.  65 

undisturbed  until  about  5  a.m.  Conversely,  a  dinner  at 
6  P.M.  is  often  followed  by  pain  soon  after  the  patient  retires 
to  bed. 

It  has  already  been  observed  that  the  pain  varies  consider- 
ably in  degree  in  different  cases  and  may  be  so  violent  as  to 
resemble  bihary  colic.  On  the  other  hand,  true  pain  may  be 
entirely  absent  during  the  whole  course  of  the  complaint  and 
gastric  distention  may  be  the  chief  symptom.  This  is  par- 
ticularly the  case  when  the  gastric  disorder  is  due  to  disease 
of  the  appendix,  and  very  many  cases  diagnosed  as  "flatulent 
dyspepsia,"  "nervous  dyspepsia,"  or  "amylaceous  indiges- 
tion" are,  in  reality,  examples  of  this  nature.  In  such,  weight, 
distention,  or  oppression  at  the  chest  is  experienced  from  the 
time  the  patient  gets  up  in  the  morning  until  he  falls  asleep  at 
night,  and  is  increased  immediately  after  meals  or  even  after  raw 
milk.  By  means  of  the  tube  the  stomach  may  be  shown  to 
contain  a  considerable  amount  of  hyperacid  gastric  juice  and 
gas  at  all  times  of  the  day,  a  fact  which  serves  to  explain  not 
only  the  permanency  of  the  discomfort,  but  also  the  inability 
to  digest  raw  milk,  which  probably  coagulates  in  large  masses 
directly  it  is  brought  into  contact  with  the  gastric  contents. 
As  a  rule,  the  true  pain  of  hypersecretion  is  relieved  not  only 
by  the  ingestion  of  proteid  food,  but  also  by  a  dose  of  an  alka- 
line salt  or  a  draught  of  cold  water,  the  alkali  acting  by  neutral- 
isation of  the  free  acid  and  the  water  by  mechanical  dilution 
of  the  gastric  juice.  It  is  interesting  to  notice,  however,  that 
in  certain  cases  of  chronic  hypersecretion  due  to  disease  of  the 
appendix  the  patient  is  unfavorably  affected  by  alkalies  and 
will  often  suffer  great  discomfort  from  a  dose  of  bicarbonate 
of  sodium.  This  symptom  is  possibly  due  to  secondary 
hypereesthesia  of  the  gastric  mucous  membrane  and  is  so 
significant  that  I  have  often  been  able  to  diagnose  the  appen- 
dicular disease  from  its  existence.  With  regard  to  the  local- 
isation of  the  pain,  its  maximum  intensity  is  usually  found  to 
coincide  with  the  position  of  the  pylorus,  whence  it  radiates 

5 


66  CHRONIC  HYPERSECRETION. 

over  the  epigastrium  and  front  of  the  chest.  When  the 
sensation  is  referred  to  the  right  hypochondrium  and  back, 
gall-stones  are  sometimes,  though  by  no  means  invariably,^ 
found  to  be  the  cause  of  the  hypersecretion,  while  in  not  a 
few  cases  of  latent  disease  of  the  appendix  pressure  over 
McBumey's  point  produces  pain  in  the  epigastrium,  or  vice 
versa. 

Vomiting  occurs  in  the  majority  of  cases  at  some  period  of 
the  disease,  but  varies  considerably  in  different  individuals 
and  in  different  varieties  of  the  complaint.  Some  persons 
vomit  with  the  greatest  difi&culty  and  after  suffering  tortures  of 
pain  are  obliged  to  induce  emesis  in  an  artificial  manner  in 
order  to  obtain  relief,  while  others  invariably  vomit  if  affected 
only  by  a  moderate  degree  of  gastric  discomfort.  The 
personal  factor  must,  therefore,  always  be  taken  into  con- 
sideration when  this  symptom  is  under  discussion.  Three 
varieties  of  vomiting  are  met  with  in  chronic  hypersecretion, 
the  first  of  which  occurs  at  the  crisis  of  a  painful  attack  and 
afi'ords  immediate  relief;  the  second,  which  results  from 
stenosis  of  the  pylorus  appears  late  in  the  afternoon  or  on 
retiring  to  rest,  and  procures  the  expulsion  of  an  immense 
quantity  of  acid  fluid;  while  the  third,  which  characterises 
gastric  intolerance,  is  incessant,  is  accompanied  by  much 
retching,  and  only  results  in  the  expulsion  of  a  small  amount  of 
the  green  mucoid  fluid  mixed,  perhaps,  with  altered  blood. 

Emesis  occurring  at  the  crisis  of  an  attack  of  pain  is  less 
frequent  than  is  commonly  supposed  and  is  often  voluntarily 
induced.  It  is  chiefly  confined  to  cases  where  there  is  an  open 
ulcer  of  the  stomach  and  is  indistinguishable  from  the  variety 
which  usually  accompanies  that  complaint.  Periodic  vomiting 
of  large  quantities  of  fluid  always  suggests  gastrectasis  due  to 
stricture  of  the  pylorus  or  first  part  of  the  duodenum,  or 
prolonged  spasm  of  the  pyloric  sphincter.  That  this  latter 
condition  may  closely  simulate  an  organic  stricture  is  a 
common  observation,  and  I  have  seen  many  cases  of  chronic 


SYMPTOMS.  67 

hypersecretion  in  which  prolonged  food  retention,  marked 
gastrectasis,  visible  peristalsis  of  the  stomach,  and  typical 
periodic  vomiting  have  disappeared  under  daily  lavage  and  a 
liquid  diet,  and  which  have  subsequently  been  proved  by 
operation  to  be  quite  free  from  stricture  or  even  kinking  of  the 
duodenum.  According  to  my  experience,  vomiting  is  com- 
paratively infrequent  in  hypersecretion  due  to  appendicular 
disease,  while  in  that  which  results  from  gall-stones  it  chiefly 
occurs  at  night.  Nocturnal  vomiting  is  extremely  common 
in  the  hypersecretion  that  attends  gastric  and  duodenal 
ulceration,  and  the  mere  existence  of  this  symptom  should  at 
once  excite  a  strong  suspicion  as  to  the  nature  of  the  complaint. 
In  such  cases,  after  retiring  to  rest  the  patient  usually  falls 
into  a  heavy  sleep,  which  gradually  becomes  troubled  by  a 
succession  of  short  but  terrifying  dreams.  Gradually  he 
returns  to  consciousness  between  i  and  2  o'clock  with  an 
impression  of  discomfort  in  the  chest  and  abdomen  or  with  a 
sense  of  suffocation.  Abdominal  distention,  flatulence,  and 
acid  eructations  are  soon  succeeded  by  nausea  which  finally 
culminates  in  violent  vomiting,  as  the  result  of  which  a  large 
quantity  of  a  thin,  acid,  and  often  bile-stained  fluid  is  ejected. 
The  relief  experienced  by  the  emesis  is  usually  so  profound 
that  the  patient  is  able  to  sleep  for  the  rest  of  the  night,  but  in 
advanced  cases  his  rest  continues  broken  and  unrefreshing 
until  another  attack  of  vomiting  ensues  about  5  a.m.  Aching 
in  the  throat,  headache,  thirst,  and  palpitation  of  the  heart 
are  usually  concomitant  symptoms  of  the  attack. 

In  exceptional  instances  profuse  diarrhoea  replaces  the 
emesis,  and  in  such  it  is  reasonable  to  infer  that  the  spasmodic 
contraction  of  the  pylorus  becomes  suddenly  relaxed  at  the 
crisis  of  the  attack  and  permits  the  contents  of  the  stomach 
to  pass  into  the  intestines.  Chronic  diarrhoea  may  ensue 
from  secondary  colitis. 

The  vomit  varies  considerably  in  amount  in  different  cases, 
being  especially  abundant  when  hypersecretion  is  associated 


68  CHRONIC  HYPERSECRETION. 

with  organic  stenosis  of  the  pylorus  and  gastrectasis  of  a  high 
degree.  Under  these  circumstances  a  htre  (35  oz.)  or  more 
is  often  ejected  on  the  first  occasion,  and  half  the  quantity 
a  few  hours  later,  even  when  no  food  or  drink  has  been  taken 
in  the  interval.  At  an  advanced  stage  of  the  disease,  when 
the  emesis  recurs  every  few  hours,  more  than  four  litres  (5  to  7 
pints)  may  sometimes  be  rejected  in  twenty-four  hours. 

The  vomit  itself  usually  consists  of  an  opalescent  fluid, 
often  stained  yellow  or  green  with  bile,  and  possessing  a  sour 
taste  and  smell  and  an  acid  reaction.  When  ejected  during 
the  period  of  gastric  digestion  the  material  rapidly  separates 
in  the  test-glass  into  two  layers,  the  lower  of  which  presents 
the  opaque  appearance  and  dirty  grey  colour  significant  of  un- 
digested particles  of  food,  while  the  upper  one  is  comparatively 
clear,  often  coloured  with  bile,  and  covered  by  a  thick  layer 
of  froth.  The  material  is  acid  to  litmus-paper  and  always  con- 
tains free  hydrochloric  acid  and  the  special  gastric  ferments. 
Its  total  acidity  varies  from  40  to  70.  It  is  consequently 
capable  of  digesting  threads  of  fibrin  when  kept  in  a  warm 
chamber,  and  of  curdling  milk  after  neutralisation  with  bi- 
carbonate of  sodium.  The  sediment  is  found  to  consist  of 
starch,  vegetable  fibre,  shreds  of  meat,  epithelial  cells,  and 
food  debris. 

In  rare  instances  there  is  great  intolerance  of  fat,  and  in 
such  the  vomit  may  be  like  liquid  butter  or  after  standing 
present  a  soft  crust  of  fat.  In  such  cases  chronic  duodenitis 
with  pancreatitis  usually  exists  and  is  very  often  of  syphilitic 
origin. 

From  time  to  time  attacks  of  acute  hypersecretion  are  apt  to 
supervene,  as  the  result  of  which  gastric  intolerance  becomes 
established,  and  the  patient  suffers  from  incessant  retching  and 
vomiting.  In  these  circumstances  only  an  ounce  or  two  of 
a  green  mucoid  fluid  may  be  vomited  on  each  occasion,  and 
the  proportion  of  free  hydrochloric  acid  contained  in  it  falls 
considerably  below  the  former  standard. 


SYMPTOMS.  69 

Flatulence  is  an  invariable  symptom  and  may  ensue  im- 
mediately after  meals  and  persist  all  day  or  only  occur  at  the 
height  of  gastric  digestion  and  be  reheved  by  a  sudden  expul- 
sion of  gas.  It  is  chiefly  due  to  fermentation  of  the  carbo- 
hydrate constituents  of  the  food  which  produces  an  excess 
of  carbon  dioxide,  hydrogen,  and  small  quantities  of  methane. 
A  sense  of  extreme  gastric  distention  is  always  experienced 
during  the  crisis  of  a  painful  seizure  and  probably  arises  from 
violent  contractions  of  the  stomach  accompanied  by  spasmodic 
closure  of  its  orifices.  Persistent  and  incurable  flatulence  is 
a  common  feature  of  hypersecretion  dependent  upon  disease 
of  the  appendix. 

Acid  eructations  are  met  with  in  about  60  per  cent,  of  all 
cases.  As  a  rule,  the  regurgitation  of  acid  into  the  throat 
and  mouth  occurs  chiefly  at  the  end  of  gastric  digestion  and  is 
particularly  severe  and  distressing  at  night,  but  when  the 
pyloric  orifice  is  constricted  or  constantly  contracted  by  spasm 
acidity  may  ensue  immediately  after  milk  or  other  forms  of 
food.  In  some  instances  the  heart-burn  is  replaced  by  a 
severe  aching  of  the  muscles  of  the  throat,  while  chronic 
pharyngitis  almost  invariably  ensues  within  a  few  months. 
Gall-stones  are  more  often  accompanied  by  acid  regurgitations 
than  appendicular  hypersecretion.  When  the  fluid  is  collected 
and  examined  it  is  found  to  consist  of  gastric  juice,  which 
possesses  a  high  degree  of  acidity  without  necessarily  con- 
taining hydrochloric  acid  in  a  free  state. 

Unlike  simple  hyperacidity,  chronic  hypersecretion  is 
always  accompanied  by  loss  of  flesh.  At  first  there  may  be 
only  a  general  flabbiness  of  the  tissues  with  diminished 
elasticity  of  the  skin;  but  subsequently  the  wasting  affects 
all  the  subcutaneous  fat  of  the  body,  so  that  the  skin  can  be 
picked  up  in  folds,  the  neck  grows  thin  and  cord-like,  and  the 
muscles  of  the  trunk  and  extremities  become  so  attenuated 
that  the  patient  is  no  longer  capable  of  undertaking  his  usual 
forms  of  exercise.     Finally,  when  vomiting  becomes  a  frequent 


70  CHRONIC  HYPERSECRETION. 

symptom,  the  face  grows  haggard  and  cadaverous,  the  cheek 
bones  appear  unduly  prominent,  and  the  expression  indicates 
profound  distress  and  melancholy.  The  rapidity  with  Vv'hich 
the  body  loses  weight  varies  in  different  cases,. but  it  is  always 
most  rapid  and  pronoimced  in  cases  of  cicatricial  stenosis  of 
the  pylorus  accompanied  by  frequent  vomiting.  Under  these 
conditions  I  have  knov^Ti  a  patient  to  lose  28  lb.  within  six 
weeks.  The  same  rapidity  of  emaciation  is  observed  during 
an  intercurrent  attack  of  acute  supersecretion  (gastric  intoler- 
ance). The  emaciated  and  exhausted  condition  of  a  subject 
of  h}^ersecretion,  when  associated  with  the  symptoms  and 
signs  of  pyloric  obstruction,  naturally  suggests  malignant 
disease,  and  unless  every  aspect  of  the  case  is  taken  into  con- 
sideration and  the  contents  of  the  stomach  submitted  to  a 
chemical  examination,  even  the  most  experienced  clinicians 
may  be  guilt}'  of  a  serious  error  of  diagnosis.  It  is,  therefore, 
important  to  note  that  however  emaciated  the  patient  may 
have  become,  he  seldom  displays  that  curious  loss  of  physical 
and  mental  energ}'  which  characterises  carcinoma  of  the 
stomach  almost  from  its  inception,  and  weak  though  he  may 
be  he  will  often  insist  upon  following  his  employment  or  will 
continue  to  take  an  intelligent  interest  in  it. 

AfKEmia  is  invariably  present,  and  the  complexion  often 
assumes  a  dirty,  sallow  hue;  but  unless  the  disease  is  accom- 
panied by  haemorrhage  a  cachexia  like  that  met  with  in  gastric 
cancer  is  rarely  encountered.  The  total  quantity"  of  the  blood 
becomes  steadily  reduced  as  the  disease  progresses,  but  its 
density  does  not  diminish  as  it  does  in  cases  of  carcinoma. 
As  a  rule,  there  is  an  appreciable  reduction  of  red  corpuscles, 
but  if  vomiting  is  a  frequent  symptom  a  relatively  high  count 
or  even  polycythsemia  may  exist.  It  is  important  to  observe 
that,  unlike  carcinoma,  the  corpuscular  richness  of  the  blood 
in  h)'persecretion  invariably  increases  under  appropriate 
treatment.  A  slight  increase  in  the  number  of  white  cor- 
puscles is  present  in  most  instances,  and  during  the  period 


SYMPTOMS.  71 

of  gastric  digestion  the  so-called  "digestion  leucocytosis "  may 
usually  be  observed.  The  haemoglobin  is  always  reduced  in 
severe  cases,  and  its  percentage  amount  may  fall  as  low  as  50. 

The  tongue  is  usually  moist,  red,  and  clean.  When,  how- 
ever, vomiting  is  excessive  or  the  patient  is  confined  to  a  milk 
diet,  it  is  apt  to  become  coated  with  a  grey  or  white  fur,  and 
occasionally  presents  follicular  ulcers  along  its  margins  or  at 
its  extremity. 

The  appetite  varies  at  different  stages  of  the  complaint, 
but,  as  a  rule,  a  marked  desire  for  food  is  a  notable  feature  of 
hypersecretion.  At  first,  when  the  gastric  juice  contains  an 
excess  of  hydrochloric  acid  the  patient  usually  partakes  of 
food  at  short  intervals,  partly  to  counteract  the  sensation  of 
sinking  and  faintness  which  he  experiences  so  frequently,  and 
partly  because  he  knows  that  the  ingestion  of  albuminous  food 
will  always  relieve  the  pain.  Occasionally  an  abnormal 
craving  for  nutriment  termed  "  canine  hunger  "  is  observed,  and 
large  quantities  of  food  will  be  devoured  with  avidity  a  short 
time  after  a  full  meal,  and  this  may  occur  even  after  vomiting. 
Certain  perversions  of  taste  are  occasionally  encountered, 
especially  in  cases  of  long  duration,  fats,  oils,  pickles,  con- 
diments, salt  articles,  and  starchy  foods  being  usually  regarded 
with  the  greatest  repugnance,  possibly  on  account  of  the 
increased  pain  which  their  ingestion  entails.  In  rare  instances 
a  dislike  to  meat,  similar  to  that  met  with  in  carcinoma  of  the 
fundus  of  the  stomach,  is  observed.  It  must  never  be  for- 
gotten, however,  that  in  hypersecretion  as  in  other  painful 
diseases  of  the  stomach,  an  apparent  loss  of  appetite  may 
really  be  due  to  the  fear  of  provoking  the  distress  which 
invariably  follows  indulgence  in  food.  Thirst  exists  in  every 
case,  and  is  sometimes  such  a  prominent  symptom  as  to 
suggest,  in  combination  with  the  increased  appetite  and  loss 
of  flesh,  the  possibility  of  diabetes.  It  is  always  most  severe 
when  the  stomach  is  much  dilated  and  vomiting  a  frequent 
symptom.     Unhke  most  varieties  of  thirst,  it  is  often  increased 


72  CHRONIC  HYPERSECRETION. 

rather  than  diminished  by  acid  drinks,  and  is  relieved  by  milk, 
alkaline  beverages,  and  effervescent  mineral  waters. 

The  bowels  are  always  confined,  although  attacks  of 
diarrhoea  are  apt  to  alternate  with  the  periods  of  constipation. 
The  stools  are  hard,  dry,  and  knotty,  and  much  irritation  of 
the  anus  may  be  experienced  after  an  evacuation.  At  an 
advanced  stage  of  the  complaint,  when  the  patient  is  much 
exhausted  by  continual  pain  and  vomiting,  exposure  to  cold 
or  the  administration  of  a  purgative  will  sometimes  excite 
acute  inflammation  of  the  sigmoid  flexure  and  rectum,  attended 
by  a  frequent  discharge  of  blood-stained  mucus  and  much 
tenesmus  and  colic.  An  attack  of  this  nature  sometimes 
terminates  fatally. 

The  urine  in  hypersecretion  presents  certain  peculiarities. 
The  quantity  voided  in  the  twenty-four  hours  is  always 
diminished,  and  if  vomiting  is  an  urgent  symptom  the  amount 
may  not  exceed  lo  to  15  oz.  As  a  rule,  the  fluid  is  cloudy 
when  passed,  and  deposits  a  copious  sediment  of  phosphates. 
Owing  to  its  concentration  and  its  relatively  large  proportion 
of  soluble  salts,  the  specific  gravity  usually  exceeds  the  normal. 

It  is  well-known  that  an  important  relationship  exists  be- 
tween the  activity  of  the  gastric  secretion  and  the  acidity  of  the 
urine,  the  greater  the  amount  of  hydrochloric  acid  secreted  by 
the  stomach  during  the  process  of  digestion  the  less  the  total 
acidity  of  the  urine  which  is  voided  during  that  period.  It  is, 
therefore,  not  surprising  that  in  cases  of  hypersecretion  the 
urine  is  frequently  neutral  or  alkaline  in  reaction.  The 
quantity  of  phosphates  eliminated,  expressed  in  terms  of 
phosphoric  acid,  varies  from  3 . 2  (Lyon)  to  5  grm.  (Robin) 
per  diem,  but  the  average  would  appear  to  be  about  2 . 7  grm. 
(Bouveret  and  Devic).  The  urea  is  invariably  increased, 
and  the  patient  eliminates  considerably  more  of  this  salt  than 
a  healthy  man  of  the  same  age  who  takes  the  same  quantity 
of  food.  Thus,  instead  of  the  normal  excretion  of  30-40  grm. 
of   urea   per   diem,    the   subjects   of   hypersecretion   usually 


THE    PHYSIOLOGY    OF    DIGESTION    IN   HYPERSECRETION.       73 

eliminate  about  45  grm.  in  the  twenty-four  hours,  while  not 
infrequently  the  total  amount  varies  between  50  and  60  grm. 
This  increase  is  probably  due  to  the  abnormal  activity  of 
proteid  digestion  which  occurs  as  a  result  of  the  increased 
gastric  secretion. 

A  diminution  in  the  output  of  the  chlorides  is  a  remarkable 
feature  of  the  complaint.  Instead  of  the  normal  12  grm.  only 
I  grm.  or  even  less  may  be  excreted  per  diem  (Gluzinski, 
Sticker,  Stroh).  The  greatest  diminution  occurs  in  cases 
where  the  patient  is  either  unable  to  take  nourishment,  vomits 
frequently,  or  has  his  stomach  constantly  evacuated  by  a  tube. 
According  to  Sticker  and  Stroh,  the  diminished  ehmination 
of  chlorides  is  less  dependent  upon  actual  hypersecretion 
than  on  the  stagnation  of  the  food  and  vomiting  that  accom- 
pany it;  but  it  would  seem  more  probable  that  the  excessive 
and  prolonged  manufacture  of  hydrochloric  acid  by  the  gastric 
glands  causes  a  withdrawal  from  the  blood  of  an  abnormal 
amount  of  chloride  of  sodium,  which  subsequently  becomes 
lost  to  the  organism  by  vomiting.  A  marked  diminution  of 
the  chlorides  must  be  regarded  as  a  bad  omen,  while  an  in- 
creased elimination  of  these  salts  usually  coincides  with  a 
betterment  of  the  condition  of  the  patient. 

The  secretion  of  sweat  is  usually  deficient,  and  the  skin 
is  dry  and  harsh.  In  some  instances  patches  of  brown  pig- 
mentation make  their  appearance  upon  the  forehead  and 
malar  bones  and  upon  the  anterior  surface  of  the  abdomen. 
As  a  rule,  the  pulse  is  small  and  of  low  tension,  and  if  vomiting 
is  a  frequent  symptom  the  cardiac  impulse  is  apt  to  become 
much  enfeebled  and  the  beats  may  not  exceed  78  per  minute 
(Riegel).  Owing  to  this  defective  circulation,  the  hands  and 
feet  constantly  feel  cold  and  lifeless  and  are  very  prone  to  be 
affected  by  chilblains. 

The  Physiology  of  Digestion  in  Hypersecretion. — The 
presence  of  free  hydrochloric  acid  in  the  empty  stomach  at 
once  neutralises  the  saliva  introduced  with  the  food  and  puts 


74  CHRONIC  HYPERSECRETION. 

a  stop  to  the  action  of  the  ptyalin  upon  the  starchy  constituents 
of  the  meal.  As  a  result  of  this  inhibition,  amylaceous  sub- 
stances tend  to  stagnate  in  the  organ,  and  the  gastric  contents 
obtained  after  a  test  meal  fail  to  exhibit  the  usual  reactions 
indicative  of  achroodextrin  and  maltose.  The  digestion  of 
proteids,  on  the  other  hand,  is  much  more  rapid  than  usual, 
and  an  excess  of  peptone  can  always  be  detected  in  the  material 
removed  by  a  tube.  It  is  possible,  however,  that  the  digestive 
power  of  the  gastric  juice  in  these  cases  is  to  some  extent 
nullified  by  deficient  absorption,  since  Brucke  has  shown 
that  when  gastrectasis  exists  the  accumulation  of  peptone 
gradually  inhibits  the  progress  of  proteid  solution.  It  is 
probably  owing  to  this  cause  that  fragments  of  meat  are  so 
often  found  in  the  dilated  viscus  notwithstanding  an  ab- 
normally active  gastric  juice.  There  is  no  reason  to  believe 
that  a  deficiency  of  the  peptic  ferment  ever  exists,  for  except 
in  cases  of  atrophy  of  the  stomach  a  sufficiency  of  pepsin  can 
always  be  extracted  from  the  mucous  membrane  of  the  organ 
when  treated  with  hydrochloric  acid  (Fenwick). 

Abnormal  fermentations  invariably  occur  as  the  result  of 
the  retention  of  carbohydrates,  and  are  especially  active 
during  the  later  stages  of  the  secretory  disorder  when  the 
stomach  is  dilated  and  the  degree  of  acidity  tends  to  diminish. 
In  these  circumstances  the  material  extracted  by  the  tube 
gives  off  numerous  bubbles  of  gas  if  preserved  for  a  short 
time  in  a  warm  atmosphere,  which,  on  analysis,  are  found  to 
consist  of  carbon  dioxide,  mixed  with  varying  proportions  of 
hydrogen  and  nitrogen,  and  occasionally  with  marsh  gas. 
In  rare  instances  the  mixture  is  distinctly  inflammable  (Kuhn). 
Fats  are  melted  in  the  stomach  and  occasionally  undergo 
butyric  fermentation. 

Examination  of  the  Stomach. — Inspection  of  the 
abdomen  often  affords  important  indications  of  gastric  dila- 
tation and  hypertrophy.  Thus,  when  the  pylorus  or  duodenum 
is  stenosed,  the  organ  may  form  a  distinct  prominence  in  the 


EXAMINATION    OF    THE    STOML^CH.  75 

umbilical  region,  while  the  normal  protuberance  of  the 
epigastrium  is  replaced  by  a  transverse  furrow.  Palpation  of 
the  swelling,  or  friction  of  the  skin  over  it,  usually  excites 
active  contractions  of  its  w^alls  which  appear  as  slow,  rhythmical 
waves  that  pass  across  the  tumour  from  left  to  right. 

By  the  employment  of  auscultatory  percussion  the  outlines 
of  the  stomach  may  be  accurately  mapped  out  upon  the  skin 
of  the  abdomen  and  chest,  or  the  dimensions  of  the  viscus 
may  be  rendered  visible  by  pumping  air  into  it  through  a  tube 
or  by  the  administration  of  alternate  draughts  of  tartaric 
acid  and  bicarbonate  of  sodium.  Either  of  these  methods 
will  demonstrate  that  the  stomach  is  usually  dilated  in  cases 
of  chronic  hypersecretion  and  has  also  undergone  downward 
displacement  as  a  result  of  its  increased  weight. 

In  order  to  determine  the  motor  power  of  the  organ, 
lavage  should  be  performed  in  the  early  morning  or  nine  hours 
after  a  test  dinner.  The  presence  of  undigested  food  in  the 
stomach  before  breakfast,  when  no  form  of  nourishment  has 
been  taken  since  the  previous  evening,  demonstrates  a  consider- 
able degree  of  motor  insufficiency  and  naturally  suggests 
stenosis  of  the  pylorus  or  duodenum.  The  same  condition, 
however,  may  result  from  a  spasmodic  contraction  of  the 
pylorus  without  organic  stricture,  and  I  have  often  been 
astonished  to  find  a  perfectly  patent  pylorus  at  operation  in 
cases  where  food  retention  had  been  a  marked  feature  of  the 
case.  On  the  other  hand,  daily  lavage  combined  with  a 
milk  diet  for  a  week  will  usually  abolish  the  phenomenon 
of  undigested  food  in  the  fasting  stomach  for  some  time, 
whereas  in  cases  of  organic  stricture  the  retention  recurs  as  soon 
as  sohd  food  is  substituted  for  the  milk. 

The  spasmodic  form  of  retention  is  also  much  more 
variable  in  its  appearance  and  degree  than  the  organic  form, 
and  will  often  disappear  and  recur  without  obvious  reason,  so 
that  one  morning  the  organ  will  contain  the  major  portion  of 
the  supper  taken  on  the  previous  night,  while  on  the  next  the 


76  CHRONIC  HYPERSECRETION. 

acid  fluid  withdrawn  by  the  tube  will  be  quite  clear  and  devoid 
of  sediment. 

Palpation  reveals  an  increased  sensibility  of  the  entire 
epigastric  region  and  occasionally  the  presence  of  certain 
localized  tender  areas  in  the  median  line  above  the  umbilicus 
or  just  to  the  right  of  the  navel.  Hyperaesthesia  of  the  skin  is 
rarely  encountered  and  the  special  points  of  superficial  tender- 
ness which  are  believed  by  some  neurologists  to  indicate  dis- 
ease of  different  regions  of  the  stomach  can  rarely,  if  ever,  be 
detected.  Occasionally  a  tender  tumour  may  be  felt  in  the 
region  of  the  pylorus  when  the  first  part  of  the  duodenum  or 
the  orifice  itself  is  the  seat  of  chronic  ulceration,  but  even  in 
these  cases  the  size  and  definition  of  the  mass  depend  to  a 
great  extent  on  the  coexistence  of  pylorospasm. 

Exploration  of  the  Stomach  with  a  Tube. — In  order  to  obtain 
full  and  reliable  information  concerning  the  secretory  and 
motor  powers  of  the  stomach  it  is  advisable  to  explore  the 
organ  under  three  separate  conditions.  In  the  first  instance, 
the  tube  is  inserted  in  the  early  morning  before  any  food  has 
been  taken;  in  the  second,  the  organ  is  carefully  washed  out 
overnight  and  again  explored  in  the  early  morning  before 
breakfast;  while  in  the  third  experiment,  a  test-breakfast  is 
administered  when  the  stomach  is  empty  and  the  viscus 
evacuated  at  the  expiration  of  one  hour. 

(i)  The  results  of  an  exploration  in  the  early  morning 
vary  according  to  the  condition  of  the  stomach.  In  all  cases 
of  chronic  hypersecretion  the  tube  will  evacuate  a  considerable 
quantity  of  an  opalescent  green  or  yellow  fluid  which  affords 
the  usual  tests  of  an  active  gastric  juice  and  leaves  on  the 
filter-paper  a  small  quantity  of  undigested  starch  in  a  state  of 
fine  subdivision.  When,  however,  the  secretory  disorder  is 
associated  with  organic  stenosis  of  the  pylorus  or  duodenum 
or  with  severe  pylorospasm,  the  fluid  will  be  found  to  be 
mixed  with  a  certain  amount  of  undigested  food,  while 
its   total  acidity  varies   from  40  to  75.     This  initial  experi- 


EXAMINATION    OF    THE    STOMACH.  77 

ment  serves  not  only  to  demonstrate  the  existence  of  a  con- 
tinuous secretion  of  gastric  juice,  but  may  also  constitute  an 
important  test  of  the  patency  of  the  pylorus. 

(2)  Exploration  of  the  stomach  in  the  early  morning  after 
lavage  on  the  previous  night,  no  food  or  drink  having  been 
taken  in  the  interval,  is  the  great  test  for  hypersecretion.  An 
healthy  stomach  under  these  circumstances  is  either  com- 
pletely empty  or  at  most  contains  a  drachm  or  two  of  an  alka- 
line or  slightly  acid  fluid.  In  a  case  of  hypersecretion,  on 
the  other  hand,  the  tube  will  evacuate  from  4  to  15  fl.  oz.  (118- 
443  c.c.)  of  a  turbid  greenish  or  yellow  liquid,  which  is  capable 
of  digesting  albumin  and  gives  the  usual  colour  reactions  of 
free  hydrochloric  acid.  This  fluid  is  the  secretion  of  the 
stomach  mixed  with  bile,  which  has  been  produced  without 
the  usual  stimulus  afforded  by  the  presence  of  food  and  is 
consequently  diagnostic  of  hypersecretion. 

The  rapidity  with  which  the  empty  stomach  secretes  may 
be  demonstrated  by  aspirating  the  organ  at  intervals  of  an 
hour,  when,  although  no  food  has  been  taken,  from  50-150 
c.c.  of  active  gastric  juice  may  be  withdrawn  on  each  occasion. 

The  constant  appearance  of  bile  in  the  stomach  is  probably 
due  to  the  suction  action  of  the  stomach  during  its  periods 
of  peristaltic  relaxation,  the  hypertrophied  organ  acting  like 
the  rubber  ball  of  an  evacuator. 

(3)  If  retention  of  food  has  already  been  proved  to  exist, 
the  stomach  is  thoroughly  washed  out  overnight,  no  food  or 
drink  being  permitted  subsequently,  and  a  test-breakfast 
composed  of  4  oz.  of  white  bread  or  toast  with  10-14  A- 
oz.  (300-400  c.c.)  of  weak  tea  is  administered  in  the  early 
morning.  One  hour  afterward  the  organ  is  evacuated. 
Under  normal  circumstances  only  150-200  c.c.  can  be  with- 
drawn after  the  lapse  of  an  hour,  but  in  severe  hypersecretion 
more  fluid  may  be  recovered  than  was  taken  with  the  meal. 
The  particles  of  bread  are  swollen  and  gelatinous  and  the 
filtered  fluid  is  usually  free  from  bile.     The  total  acidity. 


78  CHRONIC  HYPERSECRETION. 

instead  of  being  50-60,  may  vary  from  70  to  no,  and  the 
free  hydrochloric  acid  amount  to  o .  04-0 .  i  per  cent.  In  other 
words,  hyperacidity  usually  coexists  with  hypersecretion.  It  is 
only  in  advanced  cases  of  the  disease,  when  the  patient  is 
much  debilitated  and  vomiting  is  a  frequent  symptom,  that 
the  acidity  of  the  fluid  becomes  diminished  and  the  mineral 
acid  fails  to  appear  in  the  free  state. 

Complications. — In  addition  to  the  chronic  gastritis  and 
dilatation  of  the  stomach  which  are  invariably  discovered  after 
death  from  hypersecretion,  there  are  several  phenomena, 
which,  owing  to  their  frequent  occurrence  and  clinical  impor- 
tance, must  be  regarded  as  genuine  complications  of  the 
disease.  Of  these  the  most  interesting  are  gastric  intolerance, 
haemorrhage,  ulcer,  tetany,  cancer,  diabetes,  and  colitis. 

Gastric  Intolerance  (Acute  Intermittent  Hypersecretion). 
— This  term  is  applied  to  a  clinical  condition  frequently 
observed  during  the  later  stages  of  chronic  hypersecretion, 
which  is  characterised  by  such  excessive  vomiting  that  the 
patient  is  unable  to  retain  any  form  of  nourishment  in  the 
stomach  and  is  soon  reduced  to  a  dangerous  state  of  inanition. 
Several  explanations  have  been  offered  of  these  interesting 
attacks,  but  there  can  be  little  doubt  that  they  are  really 
identical  with  the  acute  variety  of  the  disease  which  has  been 
described  already  under  the  term  "Intermittent  Hyper- 
secretion." 

The  onset  of  the  disorder  is  marked  by  a  sensation  of 
fulness  and  distention  of  the  stomach,  loss  of  appetite,  and 
somnolence,  followed  in  a  few  hours  by  excessive  epigastric 
pain,  flatulence,  acid  regurgitation,  and  intense  nausea  and 
giddiness.  Vomiting  soon  supervenes,  and  several  times  an 
hour  the  patient  will  eject  a  few  ounces  of  a  pale  green,  acid 
fluid,  containing  mucus  and  epithelial  debris,  and  giving  the 
ordinary  reactions  of  gastric  juice.  Not  infrequently  the 
vomit  becomes  stained  with  blood  after  a  short  time,  or 
presents  a  coffee-ground  appearance.     Intense  nausea  may 


COMPLICATIONS.  79 

persist  even  in  the  intervals  of  vomiting,  and  is  always  excited 
when  an  attempt  is  made  to  sit  up  in  bed  or  to  partake  of 
nourishment.  The  exhaustion  induced  by  the  continued 
retching  and  the  inability  to  retain  food  soon  produces  a 
serious  failure  of  nutrition;  the  pulse  becomes  slow  and  feeble, 
the  temperature  of  the  body  falls  steadily  to  a  point  much 
below  the  normal,  the  mouth  is  dry,  the  lips  and  gums  are 
covered  by  sordes,  and  delirium  often  supervenes.  The 
urine  is  greatly  diminished  in  quantity,  and  only  a  few  ounces 
may  be  voided  in  the  twenty-four  hours;  while  the  loss  of  fluid 
entailed  by  the  repeated  emesis  causes  the  tissues  of  the  body 
to  shrink  and  produces  an  extraordinarily  rapid  loss  of  weight. 
If  appropriate  treatment  is  adopted  the  vomiting  gradually 
ceases,  the  evidences  of  distress  subside,  the  pulse  becomes 
stronger,  and  the  secretion  of  urine  is  increased.  Unfor- 
tunately, however,  the  nature  of  the  malady  is  often  mis- 
understood, and  the  case  is  apt  to  be  treated  as  one  of  simple 
inflammation  of  the  stomach.  Under  these  circumstances  the 
general  nutrition  becomes  so  much  impaired  that  the  patient 
succumbs  to  failure  of  the  heart,  in  spite,  perhaps,  of  a  belated 
attempt  to  combat  the  exhaustion  by  rectal  feeding.  A  cor- 
rect diagnosis  is  easily  made  if  all  the  facts  of  the  case  are 
taken  into  consideration  and  the  vomit  be  submitted  to 
analysis,  since  the  symptoms  of  chronic  hypersecretion  are 
sufficiently  characteristic  to  excite  immediate  suspicion  as  to 
their  nature,  while  the  constant  presence  of  free  hydrochloric 
acid  in  vomit  unmixed  with  food  is  practically  pathognomonic 
of  the  disease. 

Hczmorrhage. — Bleeding  from  the  stomach  is  met  with  in 
rather  more  than  one-half  of  all  cases  of  chronic  hypersecretion. 
It  is  most  frequently  observed  during  attacks  of  gastric  intoler- 
ance, when  the  ejecta  are  apt  to  be  either  stained  with  blood 
or  to  present  the  appearance  of  coffee-grounds.  This  form  of 
haemorrhage  is  due  to  oozing  of  blood  from  the  general  surface 
of  the  gastric  mucous  membrane,  which,  owing  to  the  irritant 


8o  CHRONIC  HYPERSECRETION. 

action  of  the  hyperacid  secretion  with  which  it  is  constantly 
bathed,  is  intensely  congested  and  affected  with  numerous 
interstitial  hemorrhages  and  erosions.  This  form  of  haema- 
temesis  is  never  dangerous,  and  subsides  as  soon  as  the 
vomiting  ceases,  but  it  may  have  the  effect  of  partially  neutral- 
ising the  free  acid  of  the  secretion  and  thus  obscuring  the  most 
characteristic  phenomenon  of  hypersecretion.  In  some  cases 
melaena  accompanies  or  even  replaces  the  haematemesis. 

Severe  hemorrhage  only  occurs  when  the  stomach  or 
duodenum  is  the  seat  of  simple  chronic  ulcer.  In  this  con- 
dition the  bleeding  is  apt  to  recur  at  short  intervals  and  often 
proves  the  immediate  cause  of  death. 

Simple  Ulcer. — Although  it  is  universally  admitted  that 
chronic  hypersecretion  is  a  common  sequela  of  gastric  and 
duodenal  ulcer,  the  fact  that  a  continuous  secretion  of  a 
hyperacid  gastric  juice  due  to  gall-stones  or  appendicular 
disease  is  capable  of  exciting  similar  ulceration  is  not  usually 
recognised.  It  has  already  been  noticed  that  hypersecretion 
is  always  accompanied  by  a  severe  form  of  gastritis  and  that 
during  an  acute  phase  of  the  disorder  the  mucous  membrane 
becomes  deeply  congested  and  profusely  studded  with  puncti- 
form  haemorrhages  and  haemorrhagic  erosions,  the  latter  of 
which  frequently  ooze  blood  and  thus  give  rise  to  haematemesis 
and  melaena.  These  erosions,  instead  of  healing,  occasionally 
enlarge  and  coalesce  with  the  ultimate  production  of  super- 
ficial ulcers  of  considerable  size,  which,  although  easily  seen 
as  soon  as  the  stomach  has  been  opened,  cannot  he  detected  on 
external  examination  of  the  organ.  In  several  cases  of  this 
kind  I  have  known  ulcers  more  than  an  inch  in  diameter  and 
extending  to  the  muscular  coat  not  only  escape  detection  by 
the  surgeon,  but  remain  unsuspected  by  the  pathologist  until 
the  stomach  had  been  opened.  I  have  also  observed  more 
than  one  instance  of  repeated  haematemesis  or  malsena  in 
which  the  most  careful  examination  of  the  stomach  and  duo- 
denum at  operation  failed  to  detect  any  signs  of  ulcer,  but 


COMPLICATIONS.  8 1 

where  the  removal  of  unsuspected  gall-stones  or  a  diseased 
appendix  was  followed  by  a  complete  cure  not  only  of  the 
haemorrhage,  but  also  of  the  concomitant  hypersecretion.  It 
is  certain,  therefore,  that  just  as  small  erosions  have  a  natural 
tendency  to  heal,  so  the  large  superficial  ulcers  also  undergo 
complete  repair  when  their  exciting  cause,  namely,  gastric 
hypersecretion,  is  taken  away.  ■■  ; 

On  the  other  hand,  when  healing  fails  to  ensue  owing  to 
the  excess  of  free  hydrochloric  acid  the  ulcer  gradually  deepens, 
its  edges  and  base  become  thickened,  and  it  finally  presents 
those  characteristic  features  of  the  chronic  ulcer  which  permit 
its  detection  on  examination  of  the  external  surface  of  the 
stomach.  This  conversion  of  an  acute  into  the  chronic  form 
of  gastric  ulcer  can  often  be  observed  in  practice.  Thus,  in 
a  case  of  chronic  duodenal  ulcer  attended  by  severe  hyper- 
secretion which  came  under  my  care,  the  patient  was  suddenly 
attacked  by  symptoms  of  acute  gastric  ulcer,  and  when  he 
subsequently  consented  to  operation  the  original  trouble  in 
the  duodenum  was  found  to  be  accompanied  by  two  ulcers 
of  posterior  wall  of  the  stomach,  which  were  obviously  of  more 
recent  origin.  These  considerations  help  to  explain  the  fact 
that  in  about  7  per  cent,  of  all  cases  a  duodenal  ulcer  is  ac- 
companied by  one  or  more  ulcers  in  the  stomach  and  also 
the  frequent  association  of  duodenal  ulcer  with  gall-stones  as 
well  as  its  occasional  occurrence  with  latent  disease  of  the 
appendix.  I  have  also  no  hesitation  in  saying  that  many  of 
the  cases  of  haematemesis  in  which  no  ulcer  is  found  at  opera- 
tion, as  well  as  those  of  haemorrhagic  erosions  accompanied 
by  vomiting  of  blood  for  which  various  names  have  been 
invented  of  recent  years,  are  usually  dependent  upon  un- 
diagnosed hypersecretion,  of  which  gall-stones  or  disease  of  the 
appendix  is  often  the  cause. 

Tetany. — Since  Kussmaul  in  1869  drew  attention  to  the 
occasional  occurrence  of  tetany  in  cases  of  dilatation  of  the 
stomach,  the  disorder  has  become  recognised  as  an  important 
6 


82  CHRONIC  HYPERSECRETION. 

complication  of  chronic  hypersecretion.  In  the  great  majority 
of  the  recorded  cases  the  gastrectasis  was  found  to  depend  upon 
the  existence  of  a  chronic  simple  ulcer  or  its  scar  on  the 
gastric  side  of  the  pylorus,  but  in  some  instances  the  ulcer 
was  situated  either  in  the  duodenum  (Bamberger,  Renvers, 
Dujardin-Beaumetz),  or  involved  both  the  stomach  and  the 
first  portion  of  the  bowel  (Loeb,  Miiller,  Neumann,  Thiroloix). 
Cancerous  infiltration  of  a  simple  ulcer  has  been  observed 
three  times  (Bouveret  and  Devic,  Riegel,  Richartz),  In  rare 
instances  tetany  ensues  from  other  causes  of  gastric  dilatation 
than  ulcer.  Thus,  in  one  of  Miiller's  cases  an  hour-glass 
deformity  of  the  stomach  was  accompanied  by  twisting  of  the 
duodenum;  Blazicek  has  related  one  in  which  the  pressure 
of  an  enlarged  gall-bladder  had  given  rise  to  obstruction  of 
the  first  part  of  the  duodenum,  while  in  a  case  of  my  own, 
published  by  Young,  a  chronic  ulcer  of  the  lesser  curvature 
had  produced  twisting  and  obstruction  of  the  second  part  of 
the  duodenum.  Even  compression  of  the  first  part  of  the 
intestine  by  a  cyst  of  the  pancreas  has  proved  fatal  by  tetany 
(Berlizheimer). 

A  careful  analysis  of  the  symptoms  presented  by  the 
various  cases  appears  to  indicate  that  a  tonic  contraction  of 
the  muscles  of  the  extremities  is  not  the  only  feature  of  the 
nervous  complaint,  but  that  general  convulsions  of  an  epileptic 
or  tetanic  nature  are  also  apt  to  supervene.  The  nervous 
phenomena  may  therefore  be  divided  into  three  classes: 

(i)  A  form  of  tonic  contraction  of  the  muscles  of  the 
extremities  closely  allied  in  its  general  features  to  true  tetany. 

(2)  An  intermittent  form  of  spasm  attacking  the  muscles 
of  the  trunk,  especially  those  of  the  jaw,  neck,  back,  and 
respiratory  system. 

(3)  General  convulsions  of  short  duration,  attended  some- 
times by  loss  of  consciousness,  and  resembling  ordinary 
epileptic  fits. 

The  two  latter  varieties  never  occur  alone,  but  are  always 


COMPLICATIONS.  83 

associated  with  the  first  mentioned,  which  must  therefore  be 
regarded  as  the  fundamental  type  of  the  disease. 

(i)  Tonic  spasm  of  the  muscles  of  the  extremities  was 
the  initial  symptom  in  every  case  that  has  been  recorded. 
It  usually  develops  quite  suddenly  after  a  severe  attack  of 
vomiting  or  diarrhoea,  but  it  is  sometimes  preceded  by  a  sense 
of  numbness,  tingling,  or  stiffness  of  the  hands  and  feet.  In 
typical  cases  the  elbows  and  wrists  are  semiflexed  and  the 
forearms  strongly  pronated;  the  fingers  are  drawn  together 
and  firmly  bent  over  the  thumbs,  while  the  palms  are  hollowed 
by  the  approximation  of  the  thenar  and  hypothenar  eminences. 
In  the  lower  limbs  the  toes  are  bent  downward  and  adducted; 
the  soles  of  the  feet  are  hollowed,  and  the  heels  are  drawn  up 
by  the  contraction  of  the  muscles  of  the  calves.  Considerable 
pain  is  experienced  during  the  continuance  of  the  spasm,  and 
in  many  instances  the  affected  parts  appear  blue  and  are 
perceptibly  cold  to  the  touch.  The  condition  of  the  super- 
ficial reflexes  is  variable,  but  the  deep  reflexes  are  much 
exaggerated,  and  the  muscles  react  more  readily  than  usual 
to  the  interrupted  current.  Sometimes  an  attack  can  be 
induced  by  percussing  or  stroking  the  skin  of  the  epigastrium 
(Miiller,  Gerhardt),  by  the  administration  of  an  enema,  by 
the  passage  of  a  stomach-tube  (Collier,  Fenwick),  or  by  com- 
pressing the  main  artery  of  a  limb. 

The  other  phenomena  associated  with  this  condition  are 
neither  uniform  nor  of  great  importance.  The  pupils  are 
often  contracted  during  an  attack,  but  they  still  react  both  to 
light  and  accommodation.  Severe  headache  is  a  frequent 
cause  of  complaint,  and  occasionally  profuse  perspirations 
are  observed.  Retention  of  urine  occurs  in  the  majority  of 
the  cases,  and  when  the  fluid  is  withdrawn  by  catheter  it 
may  be  found  to  contain  albumin.  Sugar  and  acetone  are 
occasionally  detected  in  it  (Fenwick,  Biscaldi).  Cutaneous 
sensibility  rarely  undergoes  any  noticeable  alteration,  but  in  a 
few  instances  transient  hypersesthesia  or  anaesthesia  has  been 


84  CHRONIC  HYPERSECRETION. 

observed.  The  pulse  is  full  and  regular,  the  breathing  quick 
and  shallow,  and  the  face  and  extremities  usually  show  signs 
of  cyanosis.  The  temperature  of  the  body  is  depressed  at 
first,  but  in  fatal  cases  it  often  rises  and  may  reach  109°  F. 
before  death  (Collier).  The  intellect  usually  remains  un- 
affected. In  almost  every  case  the  first  attack  is  followed 
within  a  short  time  by  several  others,  but  occasionally  the 
second  seizure  is  separated  from  the  first  by  an  interval  of 
several  months.  In  only  one  instance  has  death  taken  place 
in  the  first  attack  (Fenwick).  The  actual  duration  of  the 
spasm  is  also  liable  to  considerable  variation,  lasting  in  some 
instances  from  five  minutes  to  six  hours  while  in  others  it 
remains  persistent  for  three  or  four  days. 

Nearly  50  per  cent,  of  the  cases  in  which  tonic  spasm  was 
the  only  symptom  terminated  fatally,  death  being  usually 
ushered  in  by  delirium,  a  quick  pulse,  and  a  rapid  rise  of  tem- 
perature, followed  by  coma  with  dilated  pupils.  In  some 
instances  the  patient  retained  consciousness  until  the  last, 
and  succumbed  to  gradual  respiratory  and  cardiac  failure. 

In  nearly  one-half  of  the  cases  the  condition  of  simple 
tetany  was  complicated  by  convulsive  seizures  which  affected 
the  muscles  of  the  neck,  jaw,  back,  and  face.  These  attacks 
were  intermittent  in  character  and  lasted  from  a  few  minutes 
to  half  an  hour,  disappearing  as  suddenly  as  they  came  on, 
and  leaving  the  muscles  in  a  state  of  semi-rigidity.  During 
their  continuance  the  patient  was  unable  to  open  the  mouth 
or  to  swallow,  and  in  several  cases  opisthotonos  was  a  marked 
symptom.  This  form  of  convulsion  must  therefore  be  re- 
garded as  a  species  of  tetanus,  and,  like  the  surgical  variety 
of  that  disease,  its  appearance  is  always  a  sign  of  the  deadliest 
import,  for  in  every  instance  where  it  has  occurred,  death 
ensued  from  failure  of  the  respiration. 

In  about  12  per  cent,  of  the  entire  number,  the  initial  tetany 
is  said  to  have  been  followed  by  convulsions  which  were 
indistinguishable    from    those    of    ordinary    epilepsy.     The 


COMPLICATIONS.  85 

fits  were  repeated  in.  rapid  succession,  and  a  fatal  termination 
was  recorded  in  two-thirds  of  the  cases. 

The  theory  which  enjoys  the  widest  acceptance  at  the 
present  time  attributes  the  nervous  symptoms  to  the  ab- 
sorption of  some  organic  poison,  produced  in  the  dilated 
stomach  by  bacterial  action  (autointoxication).  According  to 
Bouveret  and  Devic,  the  connecting  link  between  the  two 
affections  is  to  be  found  in  the  excessive  and  continuous 
secretion  of  gastric  juice.  These  observers  were  able  to 
separate  from  the  gastric  contents  of  one  of  their  cases  a  sub- 
stance that  was  soluble  in  alcohol,  and  which  gave  rise  to 
convulsions  when  injected  into  animals.  Fleiner  is  also  stated 
to  have  obtained  somewhat  similar  results.  On  the  other 
hand,  Jaksch  and  Berlizheimer,  Miiller,  and  Blazicek,  all 
failed  to  obtain  a  specific  poison  from  the  cases  under  their 
care,  while  Gumprecht's  elaborate  investigations  were  also 
negative  in  their  results.  The  last  writer  also  points  out 
that  whenever  an  organic  poison  is  absorbed  from  the  gas- 
trointestinal tract  a  certain  proportion  must  be  eliminated 
by  the  kidneys,  and  he  was  able  to  demonstrate  in  one  case 
that  the  renal  secretion  possessed  an  abnormally  high  urotoxic 
coefiicient,  which,  however,  continued  both  during  the  attacks 
and  in  the  intervals.  Ewald  and  Jacobson  extracted  a  body 
allied  to  ptomaine  from  the  urine  in  one  case. 

With  regard  to  the  possible  influence  of  hyperchlorhydria 
it  may  be  noticed  that  an  excess  of  the  acid  was  absent  in  the 
case  recorded  by  Blazicek,  and  that  tetany  has  been  observed 
in  pyloric  obstruction  due  to  cancer  and  external  pressure, 
conditions  which  are  not  usually  accompanied  by  excessive 
acidity  of  the  gastric  juice.  While,  therefore,  it  is  highly 
probable  that  the  nervous  symptoms  are  due  to  autointoxi- 
cation, there  is  at  present  no  proof  that  hydrochloric  acid  is  an 
indispensable  factor  in  their  production. 

According  to  Gumprecht,  nearly  three-quarters  of  the  cases 
of  tetany  occur  between  the  months  of  January  and  March, 


86  CHRONIC  HYPERSECRETION. 

and  there  can  be  no  doubt  that  the  disorder  is  exceptionally- 
rife  during  the  cold  months  of  the  year.  The  greater  hability 
of  men  to  the  complaint  obviously  depends  upon  the  greater 
frequency  of  chronic  ulceration  of  the  pylorus  and  duodenum 
in  the  male  sex. 

Carcmoma. — A  simple  chronic  ulcer  is  always  liable  to 
become  the  seat  of  a  cancerous  growth,  and  under  these  cir- 
cumstances the  hypersecretion  which  accompanied  the  initial 
disease  may  continue  for  some  time  after  the  development 
of  the  neoplasm.  Very  rarely  is  hypersecretion  followed  by 
carcinoma  without  an  intermediary  ulcer.  Of  this  interesting 
condition,  however,  I  have  met  with  four  examples,  all  of 
which  occurred  in  men  of  middle  age.  In  each  instance  the 
pylorus  was  affected  by  a  columnar-cell  growth  which  gave  rise 
to  stenosis  of  the  orifice.  The  disease  progressed  with  ex- 
traordinary rapidity,  and  the  average  duration  of  life  was  less 
than  nme  months.  A  tumour  was  present  in  three  cases,  and 
formed  a  sausage-shaped  mass  extending  from  the  pylorus 
along  the  lesser  cur^'ature.  Xo  secondary  growths  occurred 
in  the  liver  or  peritoneum,  but  the  perigastric  and  retroperi- 
toneal lymphatic  glands  were  found  to  be  much  enlarged  at 
the  autopsy.  The  most  interesting  feature  of  these  cases  was 
the  occurrence  of  repeated  haemorrhages,  due  apparently  to 
digestion  of  the  soft  cancerous  tissue  by  the  hyperacid  gastric 
secretion  and  the  erosion  of  blood  vessels  of  considerable  size 
situated  in  the  deeper  portions  of  the  tumour.  In  two  in- 
stances death  ensued  as  a  result  of  excessive  loss  of  blood, 
while  in  another  fatal  asthenia  ensued  from  an  attack  of 
gastric  intolerance. 

Chronic  ulcer  of  the  duodenum  is  always  liable  to  set  up 
chronic  pancreatitis,  and  consequently  diabetes  is  an  occasional 
comphcation  of  hypersecretion.  The  urine  should,  therefore, 
be  examined  for  sugar  at  regular  intervals. 

Inflammation  of  the  colon  complicates  a  large  proportion 
of  the  cases  of  hypersecretion  owing  to  irritation  of  the  intestine 


COURSE    AND    TERMIXATION.  87 

by  the  abnormal  acidity  of  the  gastric  contents.  In  this 
condition  the  first  motion  of  the  day  is  apt  to  be  followed  by 
several  evacuations  of  stringy  or  jelly-like  mucus;  griping  pains 
are  experienced  in  the  region  of  the  sigmoid  flexure  in  the  early 
morning,  and  much  complaint  is  made  of  uneasy  sensations 
in  the  umbilical  region,  nausea,  giddiness,  distention,  and 
borborygmi.  Concretions  or  inflammation  of  the  appendix 
sometimes  ensue  and  the  colitis  does  not  necessarily  improve 
after  successful  gastro-jejunostomy.  Pharyngitis  as  well  as 
postnasal  and  laryngeal  catarrh  almost  invariably  accompany 
the  gastric  disorder  and  are  never  cured  as  long  as  the  stomach 
continues  to  secrete  an  excess  of  acid.  Many  professional 
singers  and  public  speakers  have  been  obliged  to  abandon 
their  profession  on  account  of  these  troublesome  complications 
of  hypersecretion. 

Course  and  Termination. — Chronic  h}-persecretion  is  a 
disorder  of  long  duration  and  may  persist  for  twent}'  or  even 
thirty  years.  The  most  protracted  cases  are  those  which 
ensue  from  appendicitis  in  early  life  or  where  the  gall-bladder 
is  occupied  by  a  single  calculus.  An  ulcer  situated  on  the 
posterior  and  outer  wall  of  the  first  or  second  part  of  the 
duodenum  is  comparatively  seldom  accompanied  by  hemor- 
rhage or  perforation,  and  I  have  known  several  instances  of 
this  kind  in  which  the  disease  had  persisted  for  eighteen 
years  or  longer  before  it  was  diagnosed  and  an  operation  un- 
dertaken for  its  cure.  As  a  rule,  however,  the  excessive  pain, 
vomiting,  and  emaciation  that  ensue  from  an  ulcer  either 
demand  operation  or  terminate  fatally  within  fifteen  years. 
Regarded  strictly  from  a  clinical  point  of  \iew,  the  various 
cases  may  be  arranged  in  three  classes  according  to  the  severity 
of  their  symptoms  and  their  probable  causation: 

(i)  In  the  first  or  mildest  tj-pe  the  disorder  usually  displays 
an  intermittent  character  for  several  years,  the  attacks  them- 
selves being  attributed  by  the  patient  either  to  a  chill,  mental 
worry,  or  to 'some  indiscretion  in  diet.     When  the  complaint 


55  CHRONIC  HYPERSECRETION. 

assumes  a  chronic  form,  persistent  flatulence,  abdominal 
distention,  gaseous  eructations,  want  of  appetite,  giddiness 
and  constipation,  and  a  sense  of  general  malaise  or  "bilious- 
ness" constitute  its  principal  syinptoms.  Vomiting  and 
acidity  rarely  exist,  but  the  patient  remains  thin,  anasmic,  and 
nervous,  is  easily  exhausted  and  suffers  greatly  from  mental 
depression.  The  stomach  is  slightly  dilated  and  dislocated 
downward,  but  presents  neither  tumour,  local  tenderness, 
nor  visible  peristalsis.  A  tube  passed  in  the  early  morning 
sometimes  shows  the  organ  to  be  empty,  while  at  others 
several  ounces  of  active  gastric  juice  or  thick  mucus  can  be 
withdrawn,  and  after  a  test-breakfast  the  total  acidity  of  the 
filtrate  exceeds  the  normal,  and  free  hydrochloric  acid  is  usually 
present  in  excess.  It  is  important  to  notice,  however,  that  in 
many  long-standing  cases  and  especially  in  those  of  appendic- 
ular origin  the  hyperacidity  is  sometimes  replaced  by  subacidity, 
and  when  seen  for  the  first  time  this  may  prove  puzzling  to 
those  who  base  their  diagnosis  entirely  upon  a  chemical  investiga- 
tion of  the  digestive  processes,  especially  if  they  forget  that 
an  atrophic  gastritis  is  apt  to  follow  hypersecretion.  The 
history  and  general  condition  of  the  patient,  however,  are 
usually  so  characteristic  that  the  existence  of  subacidity  ought 
to  confirm  rather  than  invalidate  the  diagnosis  of  chronic 
hypersecretion. 

Cases  of  this  description  endure  a  miserable  existence  and 
are  almost  invariably  diagnosed  as  "nervous  dyspepsia"  or 
"  gastroptosis "  by  the  medical  profession  and  regarded  as 
hypochondriacs  by  their  acquaintances.  No  form  of  medical 
treatment  does  any  permanent  good,  and  even  alkalies  give 
rise  to  pain  or  discomfort.  After  many  years  they  are  usually 
attacked  by  acute  suppurative  appendicitis  which  often 
terminates  fatally.  At  the  operation  adhesions  or  other  signs 
of  former  appendicular  disease  are  often  discovered. 

(2)  In  the  second  type  the  ordinary  symptoms  of  hyper- 
secretion are  present,  and  a  certain  amount  of  pain,  with 


DIAGNOSIS.  89 

flatulence  and  acidity  are  experienced  one  or  two  hours  after 
meals.  Vomiting  occurs  occasionally  and  the  nights  are 
disturbed  by  indigestion.  The  disorder  varies  in  severity 
from  time  to  time,  but  gradually  becomes  more  troublesome  and 
refractory  to  treatment. 

Food-retention  is  frequently  found  on  evacuation  of  the 
stomach  in  the  early  morning,  but  may  be  kept  in  check  for 
some  time  by  systematic  lavage.  When  the  stomach  has 
been  washed  out  overnight  and  no  food  taken  in  the  in- 
terval several  ounces  of  green,  acid  fluid  may  be  withdrawn 
the  next  morning,  and  a  test-breakfast  shows  a  considerable 
excess  of  fluid  and  free  hydrochlorig  acid.  Cases  of  this 
description  may  be  due  to  gall-stones,  appendicitis,  or  ulcer, 
and  even  when  the  last-named  is  absent  at  first,  it  is  apt  to 
ensue  during  the  course  of  time.  The  disease  may  last  for 
many  years,  and  if  not  subjected  to  operation,  usually  ter- 
minates by  general  asthenia,  gastric  intolerance,  or  by  some 
other  complication. 

(3)  The  third  and  most  serious  variety  is  undoubtedly 
that  which  depends  upon  an  ulcer  near  the  pylorus,  either 
gastric  or  duodenal.  Pain  is  always  a  noticeable  feature  of 
these  cases  and  is  accompanied  by  typical  symptoms  of  hyper- 
secretion. The  stomach  gradually  dilates  and  when  full  of 
food  or  acid  may  present  well-marked  peristaltic  movements. 
Vomiting  and  pain  ensue  almost  every  night  between  i  and 
3  A.M.,  emaciation  makes  steady  progress,  and  intercurrent 
attacks  of  gastric  intolerance  are  usually  accompanied  by 
slight  haematemesis.  Retention  of  food  is  an  invariable 
phenomenon,  and  owing  to  the  stenosed  condition  of  the 
pylorus  does  not  disappear  after  systematic  lavage.  It  is  in 
this  condition  that  the  various  complications,  both  immediate 
and  remote,  are  usually  observed,  and  unless  the  case  is  sub- 
jected to  operation  death  invariably  results. 

Diagnosis. — Chronic  hypersecretion  is  a  complaint  that 
is  easy  to  recognise  if  attention  is  bestowed  upon  certain 


90  CHRONIC  HYPERSECRETION. 

characteristic  symptoms  and  physical  signs  of  which  the 
following  are  the  most  important:  (i)  After  many  remissions 
the  dyspepsia  has  become  permanent  and  defies  the  usual 
methods  of  treatment.  (2)  Pain  or  discomfort  ensues  regularly 
from  two  to  three  hours  after  a  meal  or  at  other  times  when  the 
stomach  is  almost  devoid  of  food.  (3)  Vomiting  often  occurs 
at  the  crisis  of  an  attack  of  pain  and  is  especially  frequent  about 
midnight,  when  the  ejecta  consist  of  a  greenish,  acid  fluid  that 
contains  an  excess  of  free  hydrochloric  acid.  (4)  The 
appetite  is  usually  increased  and  severe  thirst  may  be  experi- 
enced after  vomiting.  (5)  The  urine  is  often  scanty,  cloudy, 
contains  an  excess  of  phosphates,  and  is  deficient  in  chlorides. 
(6)  The  patient  steadily  loses  flesh  and  strength  and  may 
exhibit  marked  cachexia.  (7)  The  stomach  is  dilated  and 
signs  of  pyloric  stenosis  are  often  present.  (8)  Exploration  with 
a  tube  in  the  early  morning,  after  lavage  has  been  performed 
on  the  previous  night,  shows  the  stomach  to  contain  from  6 
to  20  fl.  oz.  of  an  opalescent,  greenish  or  yellow  acid  liquid 
which  exhibits  the  usual  characters  of  an  active  gastric  juice. 

In  the  absence  of  a  methodical  examination  of  the  gastric 
contents  hypersecretion  may  present  certain  difficulties  of 
diagnosis  and  may  be  mistaken  for  other  complaints  that  are 
accompanied  by  severe  gastric  symptoms.  Of  these  the  most 
important  are  hyperacidity,  carcinoma,  simple  chronic  gas- 
tritis, biliary  colic,  and  diabetes. 

The  differential  diagnosis  of  hyperacidity  has  already  been 
discussed.  In  this  complaint  pain  ensues  much  sooner 
after  food,  is  immediately  relieved  by  an  alkaline  draught  or 
a  light  meal,  and  subsides  spontaneously  after  the  eructation 
of  gas  or  an  action  of  the  bowels.  Vomiting  never  occurs, 
sleep  remains  undisturbed,  emaciation  and  cachexia  are 
absent  and  rapid  improvement  ensues  when  an  appropriate 
treatment  is  adopted.  On  examination  the  stomach  is  found 
to  be  empty  in  the  early  morning,  while  after  a  test-breakfast 
only  a  slight  excess  of  hydrochloric  acid  can  be  detected. 


DIAGNOSIS.  91 

There  are  many  points  of  similarity  between  severe  hyper- 
secretion and  gastric  cancer.  In  both  diseases  pain  and  sickness 
occur  after  food;  emaciation,  debility,  and  cachexia  are  often 
present;  and  there  are  signs  of  gastrectasis,  accompanied,  per- 
haps, by  a  tumour  of  the  pylorus.  On  the  other  hand,  careful 
investigation  will  always  prove  that  the  similarity  of  the  two 
complaints  is  more  apparent  than  real,  while  the  results  of  a 
gastric  analysis  are  absolutely  different  in  the  two  cases. 
Cancer  of  the  stomach  is  a  much  more  rapid  and  debilitating 
disease  than  hypersecretion  and  its  duration  rarely  exceeds 
eighteen  months.  From  the  outset  the  malignant  complaint 
is  accompanied  by  a  sense  of  exhaustion  and  mental  apathy 
that  is  wanting  in  the  secretory  disorder,  and  the  loss  of  appetite 
or  loathing  of  animal  food  affords  a  marked  contrast  to  the 
extreme  hunger  that  so  often  attends  hypersecretion.  In 
cancer,  pain  may  be  absent,  but  when  it  exists  it  is  constant 
rather  than  intermittent,  ensues  soon  after  meals,  and  is 
increased,  but  never  relieved  by  food.  Haematemesis  may 
occur  at  intervals,  is  usually  of  the  coffee-ground  variety, 
and  is  accompanied  by  a  cachexia  that  does  not  improve 
under  treatment.  Emaciation  is  rapid  and  progressive, 
oedema  of  the  ankles  and  thrombosis  of  veins  are  apt  to 
develop  and  there  is  a  degree  of  mental  depression  and  hope- 
lessness that  is  never  met  with  in  the  functional  disorder.  A 
tumour  connected  with  the  pylorus  may  occur  in  both,  but 
whereas  in  cancer  it  presents  a  nodular  surface,  a  rapid  growth, 
and  is  very  tender  on  pressure,  the  inflammatory  mass  often 
varies  in  size  and  definition  from  time  to  time  according  to  the 
degree  of  pyloric  spasm,  is  quite  smooth,  and  never  grows 
rapidly.  The  coexistence  of  enlargement  of  the  liver,  nodules 
in  the  skin  of  the  abdomen,  or  fluid  in  the  peritoneal  or  pleural 
cavities  all  bespeak  the  probability  of  a  malignant  growth. 
But  the  most  important  factor  in  the  diagnosis  is  the  state  of 
the  gastric  secretion.  In  cancer  of  the  stomach  the  vomit  is 
largely  mixed  with  mucus  and  contains  no  free  hydrochloric 


92  CHRONIC  HYPERSECRETION. 

acid,  while  the  material  obtained  after  a  test-breakfast  presents 
little  signs  of  digestion,  and  the  filtrate  is  found  to  possess  an 
abnormally  low  acidity  with  an  absence  of  the  free  mineral 
acid.  Lactic  acid  is  often  present.  In  the  early  morning, 
after  lavage  on  the  previous  night,  only  a  little  opalescent 
fluid  devoid  of  free  hydrochloric  acid  can  be  withdrawn  by 
the  tube.  When  a  simple  ulcer  has  become  the  seat  of  a 
cancerous  growth  the  antecedent  hypersecretion  sometimes 
persists  for  a  few  months. 

Simple  chronic  gastritis  does  not  present  the  two  symptoms 
that  are  characteristic  of  hypersecretion,  namely,  the  painful 
crises  and  the  vomiting  of  large  quantities  of  acid  gastric  juice. 
On  the  other  hand,  the  subjects  of  this  complaint  suffer  from 
distention  and  flatulence  within  one  hour  after  each  meal, 
and  when  they  vomit  the  ejecta  consists  of  undigested  food 
mixed  with  much  mucus  but  deficient  in  hydrochloric  acid. 
Appendicular  hypersecretion  with  subacidity  may  be  indis- 
tinguishable from  simple  chronic  gastritis. 

Biliary  colic  and  enterospasm  may  be  mistaken  for  hyper- 
secretion if  attention  is  concentrated  upon  the  abdominal  pain; 
but  the  general  history  of  the  case  combined  with  an  examina- 
tion of  the  abdomen  will  soon  clear  up  any  difficulty  of 
diagnosis. 

Hypersecretion  has  more  than  once  been  mistaken  for 
diabetes  owing  to  the  coexistence  of  emaciation,  thirst,  and 
hunger.  In  ordinary  diabetes,  however,  pain  during  digestion 
and  vomiting  are  never  encountered,  while  the  special  indica- 
tions of  the  secretory  disorder  are  absent;  but  it  must  be 
remembered  that  chronic  pancreatitis  sometimes  complicates 
duodenal  ulcer  and  in  this  condition  glycosuria  may  become 
associated  with  hypersecretion. 

Treatment. — Every  case  of  chronic  hypersecretion  re- 
quires to  be  treated  upon  its  own  merits,  special  attention 
being  paid  to  the  type  of  disease,  the  degree  of  gastrectasis, 
and  the  presence  of  complications. 


TREATMENT.  93 

General. — There  is  no  remedy  so  efficient  in  relieving  the 
attacks  of  pain  and  sickness  as  methodical  lavage  of  the 
stomach,  while  in  those  numerous  examples  of  the  complaint 
where  the  perversion  of  secretion  is  associated  with  stenosis 
of  the  pylorus  the  performance  of  lavage  is  essential  to 
the  maintenance  of  nutrition.  In  every  case,  therefore, 
where  vomiting  occurs  at  night  or  food  is  found  in  the  viscus 
in  the  early  morning,  the  stomach  should  be  washed  out  at 
least  once  a  day.  The  time  at  which  the  operation  should  be 
performed  must  be  determined  by  the  peculiar  requirements 
of  each  case.  Thus,  when  sleep  is  disturbed  by  indigestion 
or  vomiting,  lavage  is  most  conveniently  undertaken  before 
the  patient  retires  to  rest,  but  in  those  cases  where  much 
muscular  insufficiency  exists  it  may  be  advisable  to  wash  out 
the  organ  again  before  breakfast.  As  a  rule,  warm  water 
containing  about  one  grain  of  bicarbonate  of  sodium  to  the 
ounce  is  the  most  suitable  fluid  for  the  purpose,  but  some 
writers  recommend  boric  acid  (io:i,ooo)  or  other  antiseptics 
for  this  purpose.  Reichmann  claims  that  irrigation  of  the 
stomach  with  a  weak  solution  of  nitrate  of  silver  (i:i,ooo) 
has  a  direct  inhibitive  influence  upon  the  secretion,  but  this 
method  has  not  been  attended  by  much  success  at  the  hands 
of  other  observers,  and  not  infrequently  gives  rise  to  severe 
pain.  It  is  a  convenient  practice  to  administer  a  dose 
of  Carlsbad  salts  through  the  tube  at  the  conclusion  of  the 
morning  lavage. 

In  all  cases  the  enlarged  and  dislocated  stomach  should 
be  supported  by  means  of  a  firm  abdominal  belt,  which  the 
patient  can  readjust  night  and  morning.  When  duodenal 
ulcer  or  gall-stones  is  the  cause  of  the  gastric  disorder,  a  few 
weeks,  treatment  at  Carlsbad  or  Marienbad  affords  consider- 
able relief,  but  if  the  stomach  is  much  dilated  mineral 
waters  in  large  quantities  should  be  avoided.  Massage  should 
never  be  recommended  owing  to  the  frequent  association  of 
hypersecretion  with  an  open  ulcer  or  a  diseased  appendix. 


94  CHRONIC  HYPERSECRETION. 

while  rubbing  of  the  stomach  in  no  way  affects  the  excessive 
secretion.     Electricity  is  also  useless. 

Diet. — The  principal  indication  in  the  arrangement  of  a 
diet  is  to  avoid  those  articles  of  food  that  stimulate  the  gastric 
secretion  and  at  the  same  time  are  not  digested  in  the  stomach. 
This  class  includes  all  amylaceous  substances  that  have  not 
been  previously  digested,  sugar,  excess  of  fats,  and  green 
vegetables.  Few  subjects  of  hypersecretion,  whether  the 
stomach  be  dilated  or  not,  are  able  to  take  bread  and  starches 
without  experiencing  a  considerable  access  of  discomfort.  On 
the  other  hand,  experience  teaches  that  the  total  exclusion  of 
starch  from  the  dietary  usually  increases  the  tendency  to  loss 
of  flesh  and  favours  constipation,  so  that  it  is  necessary  to 
devise  some  method  by  which  a  moderate  amount  of  carbo- 
hydrates may  be  given  each  day.  The  fact  that  the  constant 
presence  of  gastric  juice  in  the  stomach  at  once  inhibits 
ptyalin  digestion  and  favours  the  fermentation  of  sugar,  sug- 
gests that  the  organ  should  be  emptied  of  its  acid  contents 
before  starch  is  given,  and  that  a  suitable  quantity  of  diastase 
should  be  added  to  the  meal  to  aid  the  conversion  of  at  least 
a  proportion  of  the  amylacea  into  sugar  before  the  accumula- 
tion of  hydrochloric  acid  puts  a  stop  to  the  process.  With 
these  objects  in  view  it  is  customary  to  wash  out  the  stomach 
with  a  weak  alkaline  solution  each  morning,  and  immediately 
afterward  to  give  a  meal  consisting  of  oatmeal,  a  cereal  soup, 
bread  and  milk,  milk  pudding,  or  some  special  form  of  starchy 
food  that  has  already  been  partially  digested.  Occasionally 
a  solution  of  dextrose  may  be  given  with  advantage,  or  a  full 
dose  of  extract  of  malt  or  takadiastase  may  be  administered 
at  the  end  of  the  meal.  Bread  almost  invariably  increases 
the  pain  and  flatulence  and  should  therefore  be  omitted  in 
favour  of  thin  toast,  rusks,  starch-free  biscuits,  or  that  most 
useful  and  palatable  preparation  which  has  recently  been 
introduced,  the  Brusson-Jeune  rolls. 

Green  vegetables  never  agree,  but  well-cooked  asparagus, 


TREATMENT.  95 

cauliflower,  seakale,  or  even  stewed  celery  may  be  allowed 
in  moderation.  All  varieties  of  fruit  give  rise  to  increased 
pain  and  acidity,  more  especially  the  stone  varieties  and 
strawberries.  Apples,  baked  or  stewed,  without  sugar  and 
oranges  are  the  least  harmful. 

The  patient  should  be  encouraged  to  take  a  moderate 
amount  of  butter  and  cream  with  his  meals,  but  excess  must  be 
avoided  as  in  many  cases  they  produce  a  form  of  fat-vomiting. 
Few  subjects  of  hypersecretion  are  able  to  take  alcohol  without 
discomfort  and  very  often  an  attack  of  gastric  intolerance  can 
be  traced  to  indulgence  in  even  a  small  quantity  of  wine  or 
spirits.  Tea  always  disagrees  and  in  many  instances  coffee 
must  also  be  prohibited,  but  cocoa  made  from  the  nibs  or 
husks  and  diluted  with  milk,  or  the  plasmon  and  peptonised 
cocoas  can  usually  be  taken  with  comfort.  At  other  meals 
one  of  the  natural  alkaline  waters,  milk  and  soda  water, 
whey,  or  orange-juice  and  water  are  the  best  drinks.  Milk  is 
invaluable  in  all  cases  since  it  rapidly  fixes  free  hydrochloric 
acid  and  is  a  comparatively  slight  stimulant  to  secretion. 
When  raw  milk  gives  rise  to  immediate  discomfort  it  is  certain 
that  the  stomach  contains  a  large  amount  of  stagnant  acid,  and 
lavage  will  have  to  be  performed  for  several  days  before  the 
milk  can  be  tolerated.  In  most  cases,  however,  the  patient 
derives  the  greatest  comfort  from  a  milk  diet,  and  is 
able  to  take  from  6  to  lo  oz.,  either  raw  or  mixed  with 
lime-water,  every  two  hours.  If  milk  disagrees,  fresh  whey 
should  be  given  or  HorHck's  malted  milk  may  be  tried.  Of 
recent  years  sour  milk  prepared  in  the  manner  recommended 
by  Metchnikoff  is  regarded  by  many  as  the  true  panacea  for 
all  dyspepsias,  but,  according  to  my  experience,  it  never  agrees 
when  the  gastric  juice  contains  an  excess  of  free  acid  and  is 
consequently  unsuitable  in  hypersecretion.  On  the  other 
hand,  I  have  seen  a  few  cases  of  long-continued  "appen- 
dicular" hypersecretion  where  the  stomach  produced  a  subacid 
secretion  in  which  the  sour  milk  siave  s;reat  relief. 


96  CHRONIC  HYPERSECRETION. 

Unless  the  gastric  disorder  depends  upon  an  ulcer  of  the 
stomach,  animal  food  may  usually  be  allowed,  especially  if  it 
be  finely  minced  and  carefully  masticated.  Mutton,  lamb, 
veal,  ham,  cold  bacon,  poultry,  fresh  game,  sweetbreads,  tripe, 
calf's  head  and  feet,  or  sheep's  brains  should  be  lightly  cooked 
and  taken  at  the  midday  meal,  while  at  other  times  fish, 
meat  essences,  clear  soups,  jellies,  custards,  junket,  and  eggs 
may  be  allowed.  If  a  craving  for  food  develops  soon  after  a 
meal  it  can  usually  be  allayed  by  a  little  egg  and  milk  or 
albumin  water. 

Medicinal. — Drugs  are  administered  with  the  object  of 
allaying  pain  and  vomiting,  relieving  constipation,  and  restrict- 
ing the  secretion  of  gastric  juice. 

Pain  usually  demands  the  exhibition  of  an  alkali  with  the 
view  of  neutralizing  the  excessive  acidity.  For  this  purpose 
full  doses  of  bicarbonate  of  sodium,  solution  of  potash,  car- 
bonate of  magnesia  or  of  ammonio-magnesium  phosphate  are 
usually  given  two  hours  after  each  meal  and  repeated  if  neces- 
sary. When  much  dilatation  of  the  stomach  exists  the  solution 
of  potash  or  calcined  magnesia  is  to  be  preferred  to  the  alkaline 
bicarbonates.  Personally,  I  have  a  very  high  opinion  of 
carbonate  of  bismuth  not  only  as  an  antacid,  but  also  as  a 
gastric  sedative,  and  invariably  combine  15  grains  with  a 
similar  amount  of  bicarbonate  of  sodium  and  a  teaspoonful 
of  glycerin.  If  flatulence  is  a  troublesome  symptom,  the 
addition  of  10  drops  of  the  glycerin  of  carbolic  acid  is  of 
considerable  use.  Sedatives  are  indicated  whenever  pain  is 
severe,  in  which  case  10  to  15  minims  of  the  solution  of  mor- 
phine may  be  added  to  the  alkaline  medicine.  Belladonna  is 
occasionally  of  service,  but  it  is  apt  to  produce  dryness  of  the 
mouth  and  thirst.  A  saline  administered  in  hot  water  before 
breakfast  is  the  best  remedy  for  the  constipation,  as  it  not  only 
induces  a  free  action  of  the  bowels,  but  also  sweeps  into  the 
intestine  the  gastric  juice  which  has  collected  during  the  night 
and  thus  performs  a  kind  of  internal  lavage.     In  most  instances 


TREATMENT    OF    COMPLICATIONS.  97 

a  mixture  of  the  dried  sulphate  and  phosphate  of  sodium  is 
the  best  saline  to  employ,  but  the  artificial  Carlsbad  salts, 
the  carbonate  and  sulphate  of  magnesia,  Rochelle  salt,  or  the 
tartrate  of  potassium  may  all  be  employed  with  good  results. 
The  natural  aperient  waters  are  not  nearly  so  efficacious. 
In  very  chronic  cases  an  occasional  dose  of  calomel  at  night 
improves  the  appetite  and  removes  the  feelings  of  biliousness. 
Hypersecretion  dependent  upon  latent  disease  of  the  appendix, 
if  it  has  existed  for  many  years,  is  apt  to  be  accompanied  by  a 
form  of  secondary  gastritis  that  is  extremely  intolerant  of  any 
medicines  and  especially  of  alkalies.  The  employment  of 
opium,  belladonna,  atropine,  and  nitrate  of  silver  with  the  view 
of  directly  controlling  the  excessive  secretion  of  the  stomach  is 
never  attended  by  permanent  benefit. 

Treatment  of  Complications. — (i)  Gastric  intolerance 
requires  to  be  carefully  treated,  since  it  is  very  apt  to  give  rise 
to  fatal  inanition.  No  food  should  be  given  by  the  mouth, 
but  small  pieces  of  ice  may  be  sucked  from  time  to  time  and 
the  buccal  cavity  washed  out  at  intervals  with  warm  water. 
The  patient  must  be  confined  to  bed  as  long  as  the  vomiting 
continues,  and  the  temperature  of  the  body  should  be  main- 
tained by  adequate  clothing  and  the  use  of  hot-water  bottles. 
The  nutrition  must  be  sustained  entirely  by  enemata  of 
peptonised  milk.  It  was  formerly  the  custom  to  limit  the 
size  of  each  enema  to  2  fl.  oz.,  and  to  give  an  injection 
every  two  hours,  but  the  constant  discomfort  and  the  very 
hmited  amount  of  nourishment  that  is  absorbed  render  this 
method  quite  unsuitable.  At  the  present  time  the  use  of 
peptonised  milk  injections  in  doses  of  12  to  20  oz.  every  six 
hours  has  quite  revolutionised  rectal  feeding,  since  it  is 
found  that  not  only  can  the  nutrition  be  maintained  almost 
indefinitely  by  this  procedure,  but  the  patient  will  cease  to 
suffer  from  hunger  and  may  actually  increase  in  weight.  The 
apparatus  required  consists  of  a  soft-rubber  catheter,  about 
3  feet  of  rubber  tubing,  and  either  a  glass  reservoir  capable 
7 


98  CHRONIC   HYPERSECRETION. 

of  holding  a  pint  of  fluid  or  a  Thermos  flask  used  in  the 
inverted  position  or  a  simple  funnel.  The  patient  reclines 
upon  his  left  side  with  the  buttocks  elevated  on  a  pillow;  the 
catheter,  previously  warmed  and  oiled,  is  inserted  into  the 
rectum  for  about  6  inches,  and  the  warm  peptonised  milk 
is  allowed  to  run  slowly  through  the  tubing  into  the  bowel  from 
the  reservoir  which  is  placed  about  i  foot  above  the  level 
of  the  patient's  body.  The  main  object  to  be  kept  in  view 
is  to  ensure  that  the  milk  flows  so  slowly  into  the  intestine  that 
it  does  not  excite  peristalsis,  and  consequently  at  least  one  hour 
should  be  occupied  in  the  administration  of  15  oz.  of  milk, 
and  no  attempt  must  be  made  to  hurry  the  operation.  If 
these  precautions  are  taken  and  the  rectum  be  washed  out  with 
normal  salt  solution  night  and  morning,  the  method  may  be 
continued  until  the  vomiting  has  entirely  ceased.  Subse- 
quently, small  quantities  of  iced  whey  are  allowed  by  the 
mouth,  and  the  diet  is  gradually  increased  until  the  patient  is 
able  to  resume  his  former  mode  of  life.  Rectal  feeding  is 
apt  to  be  followed  by  parotitis  unless  the  secretion  of  saliva 
is  maintained.  For  this  purpose  the  patient  should  be  en- 
couraged to  suck  an  india-rubber  teat  at  frequent  intervals 
and  to  chew  a  little  horseradish  occasionally.  This  natural 
maintenance  of  moisture  in  the  mouth  is  of  far  greater  value 
than  the  repeated  applications  of  antiseptic  solutions  to  the 
buccal  cavity. 

Lavage  should  never  be  omitted  and  the  stomach  should 
be  carefully  emptied  of  its  acid  contents  and  washed  out  with 
an  alkaline  solution  every  six  hours,  after  which  it  is  often  a 
good  plan  to  introduce  6  oz.  of  warm  water  containing  60 
to  90  grains  of  carbonate  of  bismuth  in  suspension  into  the 
organ  through  the  tube.  The  only  other  drug  which  is  of 
any  value  in  gastric  intolerance  is  morphine,  either  in  the  form 
of  hypodermic  injection,  or  of  tincture  of  opium,  ten  drops  of 
which  may  be  added  to  each  enema. 

(2)  Hemorrhage  must  be  combated  upon  the  same  lines 


SURGICAL   TREATMENT.  99 

as  in  cases  of  gastric  ulcer.  The  patient  remains  in  bed  and  is 
fed  entirely  by  the  rectum  in  the  manner  just  described.  An 
ice-bag  may  be  applied  to  the  epigastrium.  As  a  rule,  a  pill 
containing  ^  grain  of  the  extract  of  opium  and  3  grains  of 
of  gallic  acid  is  of  greatest  value  in  checking  the  bleeding,  but 
in  some  instances  a  solution  of  adrenalin  chloride  or  a  decoction 
of  suprarenal  extract  is  also  of  use. 

(3)  Tetany  is  a  very  fatal  complication  of  hypersecretion 
and  demands  immediate  treatment.  Absolute  rest  in  bed  and 
abstention  from  food  are  essential,  and  the  nutrition  should  be 
maintained  by  enemata  of  peptonised  milk.  It  is  rarely  wise 
to  employ  a  tube  for  the  purposes  of  lavage,  since  the  intro- 
duction of  the  instrument  is  apt  to  excite  a  fresh  convulsion. 

As  soon  as  the  patient  has  been  free  from  the  spasm  for  a 
week  the  question  of  gastroenterostomy  must  be  carefully 
considered,  since  in  all  these  cases  stenosis  of  the  pylorus  or 
duodenum  exists,  and  unless  an  accessory  opening  is  estab- 
lished between  the  stomach  and  the  bowel,  the  tetany  is  sure 
to  recur  and  eventually  to  prove  fatal. 

Surgical  Treatment. — Chronic  hypersecretion  may  persist 
for  several  years  without  materially  affecting  the  general 
health,  during  which  time  careful  medical  treatment  helps  to 
suppress  the  more  important  symptoms  and  permits  the 
patient  to  lead  a  fairly  comfortable  existence.  Sooner  or 
later,  however,  in  spite  of  lavage  and  diet,  the  symptoms  of 
gastrectasis  increase  and  dangerous  attacks  of  gastric  intoler- 
ance, haemorrhage,  or  other  complication  occur  with  increasing 
frequency.  I  am  obliged  to  confess  that  out  of  nearly  a  thousand 
examples  of  the  complaint  that  have  come  under  my  care  I 
can  hardly  recall  an  instance  in  which  a  cure  can  be  said  to 
have  been  effected  without  recourse  to  operation,  while  in  a 
large  percentage  death  ensued  within  twelve  years  from  haemor- 
rhage, perforation,  appendicitis,  inflammation  of  the  liver 
or  pancreas,  progressive  malnutrition,  tetany,  or  diabetes,  or 
from  an  intercurrent  disease,  such  as  pneumonia  or  tuberculosis. 


lOO  CHRONIC  HYPERSECRETION. 

I  therefore  always  warn  the  patient's  friends  and  medical 
attendant  of  the  incurable  nature  of  the  complaint  and  re- 
commend that  the  question  of  surgical  interference  be  borne 
prominently  in  mind. 

The  cases  which,  in  my  opinion,  demand  immediate 
surgical  treatment  are  those  in  which  food  retention,  severe 
pain,  nocturnal  vomiting,  and  evidences  of  an  hypertrophied 
and  dilated  stomach  indicate  the  existence  of  a  duodenal  or 
pyloric  ulcer.  In  such  the  performance  of  gastro-jejunostomy 
by  an  expert  is  attended  by  the  most  immediate  and  brilliant 
results,  and  the  patient  usually  regains  his  former  state  of 
perfect  health.  Ulcers  of  the  cardia  or  central  zone  of  the 
stomach  are  less  satisfactory,  and  although  the  acidity  and 
pain  eventually  disappear,  it  is  necessary  to  restrict  the  diet 
for  many  months  in  view  of  the  open  sore.  In  such  cases 
gastro-jejunostomy,  by  curing  the  excessive  secretion  of  hydro- 
chloric acid,  eliminates  the  chief  obstacle  to  tissue  repair,  and 
the  ulcers  eventually  heal.  Excision  of  a  gastric  ulcer  I 
regard  as  an  unnecessary  procedure  and  one  which  greatly  in- 
creases the  danger  to  life. 

Gall-stones  which  induce  hypersecretion  are  rarely 
attended  by  characteristic  biliary  symptoms,  probably  on 
account  of  the  fact  that  the  calculus  is  often  single,  but 
they  are  often  followed  by  duodenal  ulcer.  When  the  latter 
does  not  exist,  removal  of  the  stones  is  almost  invariably 
followed  within  three  months  by  disappearance  of  the  hyper- 
secretion. If  pyloric  stenosis,  due  to  adhesion  of  the  gall- 
bladder to  the  stomach  or  secondary  duodenal  ulcer,  exists, 
gastro-jejunostomy  should  be  performed  at  the  same  time. 
Cases  of  appendicular  hypersecretion  rarely  give  a  history 
of  appendicitis,  but  the  somewhat  pecuhar  symptoms  of  the 
gastric  disorder  usually  permit  an  accurate  diagnosis  to  be 
made.  In  all  the  cases  of  this  disease  upon  which  Mr.  Herbert 
Paterson  has  operated  for  me,  removal  of  the  diseased  ap- 
pendix has  invariably  been  followed  by  subsidence  of  the 


ACHYLIA   GASTRICA.  lOI 

hypersecretion.  This  able  surgeon  also  makes  it  a  practice 
to  examine  the  appendix  and  gall-bladder  in  every  case  on 
which  he  operates,  and  in  many  instances  has  prevented  a 
future  attack  of  inflammation  of  these  organs  by  the  timely 
discovery  and  removal  of  a  calculus  or  a  diseased  appendix, 
I  am  also  quite  convinced  from  his  cases  that  the  performance 
of  gastro-jejunostomy  is  rendered  futile,  even  though  an,  ulcer 
of  the  pylorus  was  present,  if  a  diseased  appendix  is  left 
behind.  The  occasional  occurrence  of  diaphragmatic  pleurisy 
after  the  operation,  though  seldom  fatal,  seems  to  nullify  to  a 
great  extent  the  beneficial  results  of  gastro-jejunostomy,  for 
in  many  cases  of  this  description,  the  patient  is  troubled 
afterwards  by  persistent  flatulence  which  nothing  seems  to 
allay. 

3.    ACHYLIA  GASTRICA. 

(Synonyms — Subacidity;  Hypoacidity;  Hyposecretion;  An- 
acidity;  Anachlorhydria.) 
A  diminished  secretion  of  gastric  juice  accompanies  many 
diseases.  Thus,  it  is  frequently  met  with  in  pernicious  anaemia, 
in  certain  cases  of  chlorosis  and  in  diabetes,  as  well  as  in  many 
examples  of  phthisis,  chronic  Bright's  disease,  and  dilatation 
of  the  heart.  In  carcimoma  of  the  stomach  free  hydrochloric 
acid  usually  disappears,  while  in  atrophy  and  lardaceous 
degeneration  of  the  gastric  mucous  membrane  both  the  acid  and 
the  special  ferments  may  be  entirely  absent.  But  the  gastric 
secretion  may  also  become  suppressed  as  a  result  of  nervous 
inhibition  and  quite  independently  of  organic  changes  in  the 
peptic  glands.  Cases  of  this  kind  would  seem  to  be  rare, 
although  it  is  possible  that  the  disorder  is  frequently  over- 
looked owing  to  the  lack  of  systematic  investigation  of  the 
gastric  contents.  In  most  of  the  recorded  examples  it  occurred 
in  the  subjects  of  hysteria,  neurasthenia,  or  tabes,  and  there 
is  some  evidence  to  show  that  it  may  exist  as  a  congenital 
condition  (Einhorn,  Martius). 


I02  ACHYLIA  GASTRICA. 

Symptoms. — It  is  customary  to  distinguish  three  clinical 
varieties  of  achylia  gastrica,  according  to  the  presence  or 
absence  of  certain  subjective  phenomena,  but  it  is  quite  possible 
that  the  three  groups  merely  represent  successive  stages  of 
the  complaint.  In  the  first,  the  patients  experience  no  ab- 
normal symptoms  whatever,  and,  if  it  were  not  for  the  gastric 
analysis,  they  would  be  regarded  as  individuals  in  perfect 
health.  In  the  second  class,  indications  of  a  mild  disturbance 
of  the  stomach  are  accompanied  by  symptoms  of  intestinal 
indigestion;  while  in  the  third,  chronic  intestinal  indigestion 
is  the  predominant  feature  of  the  case. 

Achyha  gastrica  without  symptoms  must  be  regarded  as  a 
rare  disorder,  although  typical  examples  have  been  recorded 
by  Einhorn,  Martius,  Ewald,  Allen  Jones,  D.  Stewart,  and 
others.  Medical  advice  is  usually  sought  on  account  of 
neurasthenia  or  some  other  malady  unconnected  with  the 
digestion;  and  it  is  only  upon  investigation  that  the  gastric 
secretion  is  discovered  to  be  absent.  Cases  of  this  description 
often  recover  from  the  nervous  affection  and  remain  in  good 
health  for  many  years,  despite  the  lack  of  an  active  gastric 
juice;  but  it  is  probable  that  sooner  or  later  they  develop  some 
derangement  of  the  intestines.  According  to  Martius,  this 
latent  variety  is  often  congenital,  but  my  own  investigations 
seem  to  show  that  in  some  instances,  at  any  rate,  the  achylia 
is  the  result  of  partial  atrophy  of  the  stomach  induced  by  the 
gastritis  of  infancy. 

When  the  symptoms  of  gastric  dyspepsia  coexist  with 
those  of  an  intestinal  disturbance,  the  case  closely  resembles 
one  of  neurasthenia  of  the  stomach.  In  such,  discomfort 
and  oppression  at  the  chest  are  experienced  soon  after  each 
meal,  and  the  patient  is  unable  to  take  much  food  owing  to 
the  feeling  that  the  capacity  of  his  stomach  is  limited.  The 
appetite  is  diminished  and  capricious,  the  bowels  are  irregular 
in  their  action,  and  nausea  is  apt  to  occur  after  exertion. 
Nervous  depression  is  always  present  without  apparent  cause. 


SYMPTOMS.  103 

and  the  patient  feels  unfit  for  any  work,  whether  mental  or 
physical.  The  urine  is  abnormally  acid,  and  fails  to  exhibit 
the  alkaline  phase  that  usually  ensues  during  the  period  of 
gastric  digestion,  while  a  copious  deposit  of  uric  acid  often 
occurs  after  it  has  been  allowed  to  stand  for  a  short  time. 

In  the  intestinal  form  of  the  complaint  any  gastric  symp- 
toms which  may  exist  are  masked  by  those  arising  from  the 
abnormal  state  of  the  bowels.  Flatulence  and  abdominal 
distention  are  more  or  less  constant,  and  an  evacuation  may 
ensue  regularly  after  each  meal.  In  other  instances  diar- 
rhoea is  present,  and  the  food  appears  in  the  stools  in  an 
undigested  condition  within  a  few  hours  of  its  ingestion. 
Griping  pains  in  the  belly,  fulness  of  one  or  other  hypochon- 
drium,  irritability  of  the  bladder,  and  the  frequent  passage 
of  flatus  are  common  subjects  of  complaint.  Occasionally 
the  stools  are  liquid,  frothy,  and  foul-smelling,  or  they  contain 
an  excess  of  mucus  or  altered  blood.  Inflammation  of  the 
duodenum  is  accompanied  by  gurghng,  nausea,  vomiting,  pain 
in  the  right  h)rpochondrium  and  occasionally  by  severe 
diarrhoea  and  jaundice  (Oppler). 

In  the  first  two  forms,  or  stages,  of  the  complaint  the  general 
nutrition  remains  unaffected,  but  when  diarrhoea  sets  in  the 
patient  gradually  loses  flesh  and  strength  and  develops  signs 
of  anaemia.  It  is  uncertain  at  present  what  effect  the  disease 
exerts  upon  the  duration  of  life. 

Chemistry  of  Digestion. — An  analysis  of  the  contents  of  the 
stomach  shows  that  the  various  constituents  of  the  meal 
present  no  signs  of  digestion.  The  material  extracted  from 
the  stomach  is  also  abnormally  dry  and  devoid  of  mucus;  the 
former  feature  being  due  to  the  absence  of  the  liquid  gastric 
secretion  and  the  latter  to  failure  of  the  mucus-secreting  cells 
of  the  gastric  epithelium. 

The  total  acidity  of  the  filtrate  usually  varies  from  2  to 
6,  but  occasionally  the  extract  is  neutral  in  reaction.  Free 
hydrochloric  acid  is  invariably  absent,  and  the  combined  acid 


I04  ACHYLIA  GASTRICA. 

either  exists  only  in  minute  quantity  or  is  altogether  wanting. 
The  amount  of  pepsin  and  rennet  varies  with  the  degree  of 
acidity;  as  long  as  hydrochloric  acid  is  secreted  the  filtrate 
continues  to  exhibit  slight  digestive  properties,  but  as  soon  as 
it  is  suppressed  the  ferments  also  disappear.  Neither  peptone 
nor  propeptone  can  be  detected,  but  occasionally  sugar  and 
erythrodextrin  may  be  found  in  the  filtrate.  Lavage  of  the 
stomach  with  a  weak  solution  of  hydrochloric  acid  may 
produce  a  fluid  which  presents  slight  powers  of  digestion. 

In  the  early  stages  of  the  complaint  the  motor  power  of  the 
stomach  is  unaffected  or  may  even  be  somewhat  increased, 
but  when  intestinal  symptoms  develop  motor  insufficiency  and 
gastrectasis  usually  ensue. 

Von  Noorden  has  shown  that  the  intestine  is  capable  of 
assuming  all  the  functions  of  the  stomach  whenever  that  organ 
is  deprived  of  its  secretory  powers  without  impairment  of 
motility;  but  that  as  soon  as  the  stomach  begins  to  suffer 
from  motor  insufficiency  the  introduction  of  fermenting  food 
into  the  bowel  causes  derangement  of  intestinal  digestion. 
These  facts  serve  to  explain  the  absence  of  dyspepsia  in  many 
cases  of  achylia,  and  also  the  frequent  coexistence  of  gas- 
trectasis when  the  symptoms  of  intestinal  indigestion  are 
present. 

Diagnosis. — The  diagnosis  of  subacidity  rests  upon  the 
discovery  on  several  successive  occasions  of  a  great  diminution 
of  hydrochloric  acid  with  a  corresponding  deficiency  of  the 
ferments.  The  total  disappearance  of  the  gastric  secretion 
in  a  case  that  exhibits  neither  gastrectasis  nor  motor  insuf- 
ficiency, and  in  which  no  organic  disease  exists  in  the  other 
organs  of  the  body,  indicates  the  presence  of  achylia. 

Treatment. — As  long  as  the  patient  suffers  no  ill  effects 
from  the  absence  of  gastric  activity,  it  is  only  necessary  to 
prescribe  a  form  of  diet  which  shall  not  unduly  distend  or 
embarrass  the  stomach,  and  to  treat,  as  far  as  possible,  any 
nervous  condition  which  may  appear  to  be  responsible  for  the 


TREATMENT.  I05 

disorder.  As  a  rule,  the  diet  should  be  a  mixed  one,  and  the 
meals  should  be  taken  every  three  hours.  Milk,  eggs,  fish, 
sweetbread,  tripe,  calf's  head,  and  sheep's  brains  are  easily  di- 
gested by  the  intestine,  while  sago,  macaroni,  tapioca,  and  rice 
may  also  be  given  in  moderation.  Well-cooked  spinach,  turnips 
and  cabbage  may  be  allowed  as  well  as  a  little  stewed  fruit. 
On  the  other  hand,  salads  and  tomatoes  and  other  raw  vege- 
tables are  apt  to  disagree.  If  the  appetite  is  deficient,  the 
various  artificial  foods  which  have  undergone  partial  digestion 
may  be  given,  and  cod-liver  oil  and  the  extract  of  malt  are  some- 
times very  useful.  Catarrhal  conditions  of  the  intestine  must 
be  carefully  treated,  and  the  patient  should  take  special  pre- 
cautions against  cold.  Hydrochloric  acid  is  the  most  useful 
drug,  and  may  be  given  in  doses  of  15  or  20  minims,  diluted 
with  an  ounce  or  two  of  water,  after  each  meal,  but  some- 
times draughts  of  warm  water  containing  hydrochloric  acid 
(i  in  1,000)  are  of  greater  value.  In  most  instances  pepsin, 
the  peptenzyme  tablets,  pepsencia  or  lactopeptine  may  also  be 
employed  with  advantage,  but  pancreatin,  which  from  a 
theoretical  point  of  view  would  appear  to  be  especially  indi- 
cated, is  rarely  of  any  use.  Metchnikoff's  sour  milk  should 
always  be  given  a  trial. 

When  motor  insufficiency  develops,  lavage  with  warm 
water  should  be  performed  each  day,  and  massage  and 
electricity  may  be  tried.  Mineral  waters  often  do  more  harm 
than  good  by  producing  distention  of  the  stomach  and  thus 
predisposing  to  atony. 


CHAPTER  III. 

DYSPEPSIA  DUE  TO  THE  FAILURE  OF  THE  MUSCULAR 
POWER  OF  THE  STOMACH. 

MYASTHENIA  GASTRICA. 

(Synonyms — Atony;  Motor  Insufi&ciency.) 

By  the  term  gastric  myasthenia  is  understood  a  diminution 
of  the  elasticity  and  strength  of  the  muscular  coat  of  the 
stomach,  whereby  the  organ  is  rendered  unduly  distensible 
and  is  prevented  from  emptying  itself  within  the  normal  period 
of  time. 

Frequency. — Myasthenia  is  a  perversion  of  the  digestive 
functions  which  constitutes  the  most  frequent  cause  of 
dyspepsia  in  this  country.  According  to  my  hospital  sta- 
tistics, the  condition  was  encountered  in  32  per  cent,  of  all 
cases  of  indigestion,  while  in  my  private  practice  its  per- 
centage frequency  was  5.2. 

Sex. — Women  are  far  more  liable  to  the  complaint  than 
men,  the  ratio  of  the  two  sexes  in  my  cases  being  nearly 
3^  to  I.  The  complaint  occurs  at  all  periods  of  Hfe 
being  a  common  cause  of  dyspepsia  in  growing  children  and 
almost  a  natural  sequence  of  old  age. 

Age. — The  age  at  which  the  first  symptoms  of  the  disorder 
manifest  themselves  varies  according  to  the  sex  of  the  patient, 
women  being  most  prone  to  the  disorder  between  fifteen  and 
thirty,  while  men  chiefly  suffer  from  it  between  thirty  and 
fifty  years  of  age. 

106 


MYASTHENIA   GASTRICA. 


107 


THE  AGE-INCIDENCE   OF   MYASTHENIA  GASTRICA  IN 
MEN  AND  WOMEN  (ALL  CASES.) 


Age 

10-20 

20-30 

30-40 

40-50 

over  50 

Totals 

Males 

I3-S 

16 

25 

2S-S 

20 

100 

Females  . . 

26.4 

24.4 

15-8 

14.4 

19 

100 

Heredity. — From  the  earliest  time  writers  upon  diseases  of 
the  stomach  have  observed  that  certain  famihes  exhibit  a 
marked  tendency  to  "weak  digestion,"  and  have  expressed 
their  conviction  that  atonic  dyspepsia  is  a  disorder  that  is 
transmitted  from  one  generation  to  another.  Careful  enquiry 
has  convinced  me  that  in  nearly  42  per  cent,  of  all  cases  of 
primary  myasthenia  one  or  other  of  the  parents  will  be 
found  to  have  suffered  in  a  similar  manner,  and  that  in  three 
cases  out  of  four  (75  per  cent.)  the  predisposition  to  the  com- 
plaint is  inherited  from  the  mother.  As  might  be  expected, 
persons  who  possess  an  inherited  tendency  to  the  disorder 
usually  develop  it  at  a  comparatively  early  period  of  life,  and 
in  this  connection  it  is  interesting  to  observe  that,  as  a  rule, 
men  fall  victims  to  it  at  an  earlier  age  than  women. 


THE    AGE-INCIDENCE    OF    MYASTHENIA    GASTRICA    IN 

PERSONS  WHO  POSSESS  AN  HEREDITARY 

TENDENCY  TO  THE  COMPLAINT. 


Age 

10-20 

20-30 

30-40 

40-50 

over  50 

Total 

Males 

33 

31 

32 

4 

0 

100 

Females. .  . 

28 

31 

22 

19 

0 

100 

It  is  interesting  to  observe  that  myasthenia  is  far  more 
common  in  persons  of  tall  stature  and  spare  habit  of  body  than 


I08  MYASTHENIA   GASTRICA. 

in  those  who  are  comparatively  short  and  stout.  Thus, 
among  several  hundred  dyspeptics  of  average  height  who  were 
specially  investigated  with  regard  to  their  weight,  62  per  cent, 
of  those  who  had  always  scaled  less  than  ten  stones  were  found 
to  be  the  subjects  of  this  disorder,  while  only  37  per  cent, 
of  those  who  habitually  weighed  more  than  twelve  stones 
suffered  from  the  complaint. 

Etiology. — For  the  purposes  of  etiological  description  it  is 
convenient  to  recognise  two  varieties  of  gastric  myasthenia — 
the  primary  and  secondary. 

Primary  Myasthenia. — The  quantity  and  quality  of  the 
food  are  most  important  factors  in  the  production  of  the 
complaint.  The  habit  which  is  so  prevalent  of  indulging  in  a 
large  meal  three  or  four  times  a  day  tends  to  overdistend  the 
stomach  and  to  tax  to  the  utmost  its  motor  and  secretory 
functions.  For  a  time  this  increase  of  work  calls  forth  a 
corresponding  increase  of  power,  and  the  individual  remains 
free  from  indigestion  despite  his  apparent  efforts  to  induce 
it;  but  sooner  or  later  the  power  of  compensation  begins  to 
fail,  the  stomach  is  no  longer  able  to  empty  itself  within  the 
normal  period  of  time,  and  motor  insufficiency  develops. 
In  other  cases  the  organ  continues  to  perform  its  functions  in 
an  efficient  manner  until  an  attack  of  fever  or  the  occurrence 
of  disease  in  some  other  important  viscus  injuriously  affects 
the  musculature,  when  the  contractility  of  the  stomach  sud- 
denly fails  and  indications  of  myasthenia  manifest  themselves. 
Not  infrequently  indulgence  in  an  excess  of  milk  with  the 
view  of  improving  the  general  nutrition  is  immediately  respon- 
sible for  the  development  of  atonic  dyspepsia,  and  conse- 
quently many  sufferers  from  the  disorder  refer  the  onset  of  their 
symptoms  to  the  time  when  they  underwent  a  "rest  cure." 
Meals  taken  at  short  intervals,  even  when  they  are  composed 
of  easily  digestible  substances  in  moderate  quantities,  tend  to 
exhaust  the  muscular  power  of  the  stomach  by  interfering 
with  its  necessary  periods  of  rest,  and  it  is  probably  on  this 


ETIOLOGY.  109 

account  that  growing  children,  who  are  forced  by  anxious 
but  injudicious  mothers  to  take  nourishment  every  two  hours, 
so  frequently  fall  victims  to  motor  insufficiency. 

Many  writers  regard  the  use  of  animal  food  as  particularly 
prejudicial  to  the  muscular  integrity  of  the  digestive  organs, 
but  according  to  my  experience  meat  is  far  less  harmful  in  this 
respect  than  a  diet  which  is  largely  composed  of  liquids, 
starches,  or  vegetables.  Thus,  among  a  series  of  dyspeptics 
who  had  never  indulged  in  animal  food  more  than  once  a  day, 
and  often  only  twice  a  week,  nearly  70  per  cent,  were  found  to 
be  suffering  from  gastric  myasthenia,  while  of  those  who  were 
in  the  habit  of  taking  meat  two  or  three  times  a  day  only  49 
per  cent,  were  affected  in  a  similar  manner. 

Conversely,  nearly  75  per  cent,  of  the  dyspeptics  who 
declared  that  they  subsisted  entirely  upon  a  vegetable  diet  were 
found  to  be  suffering  from  atony  of  the  stomach.  These 
facts  amply  corroborate  the  statement  previously  made,  that 
meat  eaters  are  chiefly  liable  to  disorders  of  secretion  (h}^er- 
acidity,  etc.),  while  those  who  live  upon  substances  which 
throw  the  chief  stress  of  digestion  upon  the  intestines  are  i 
particularly  prone  to  motor  derangements  of  the  stomach. 
All  beverages,  when  taken  to  excess,  are  apt  to  induce  an 
enfeeblement  of  the  muscular  coat  of  the  viscus,  especially 
the  aerated  waters  whose  gases,  when  expelled  by  the  heat 
of  the  body,  give  rise  to  distention  and  stretching  of  the 
gastric  walls. 

But  of  all  beverages  strong  tea  is  the  most  deleterious, 
and  its  influence  in  the  causation  of  myasthenia  is  particularly 
apparent  among  the  lower  classes  who  allow  a  strong  infusion 
to  stand  for  many  hours  and  imbibe  it  at  short  intervals. 
Thus,  out  of  a  hundred  seamstresses,  laundresses,  and  dress- 
makers, who  admitted  that  they  habitually  drank  strong  tea 
to  excess,  no  fewer  than  fifty-eight  presented  the  symptoms 
and  signs  of  myasthenia,  while  of  those  who  indulged  in  both 
tea  and  coffee  the  percentage  frequency  of  the  disorder  was 


no  MYASTHENIA.  GASTRICA. 

86.  Coffee  taken  alone  is  more  often  productive  of  hyper- 
acidit}'  than  of  atony,  since  of  those  who  restricted  themselves 
to  this  beverage  only  27  per  cent,  were  found  to  be  suffering 
from  atonic  dyspepsia. 

Alcoholic  liquors  are  not  directly  provocative  of  atony, 
and  it  is  only  when  their  abuse  has  occasioned  chronic  gastritis 
that  fermentation  of  the  food  and  the  spread  of  inflammation 
to  the  muscular  tunic  give  rise  to  motor  insuflSciency. 

Prolonged  abstention  from  food  or  deprivation  of  proper 
nourishment  is  occasionally  responsible  for  gastric  myasthenia, 
and  in  this  connection  it  is  interesting  to  note  that  Bidder  and 
Schmidt  found  by  experiment  in  animals  that  the  gastric 
juice  became  greatly  diminished  as  the  result  of  starvation. 

Insufficient  exercise,  especially  if  it  be  associated  with 
defective  ventilation,  is  frequently  responsible  for  the  develop- 
ment of  the  complaint,  and  consequently  persons  who  pursue 
their  occupations  in  small  and  stuffy  rooms  are  inordinately 
subject  to  it.  Among  a  series  of  dyspeptics  who  were  classified 
according  to  their  occupation,  it  was  found  that  myasthenia 
existed  in  13  per  cent,  of  those  whose  trades  were  pursued  in 
the  open  air,  and  in  31  per  cent,  of  those  whose  work  confined 
them  to  the  house  or  factory.  Again,  when  the  indoor  oc- 
cupation was  of  a  sedentary  character  the  percentage  frequency 
of  the  complaint  was  37,  but  when  the  employment  was  of  a 
laborious  description  it  was  only  21.  According  to  Samuel 
Fenwick,  a  constrained  posture  during  work  neutralises  the 
beneficial  effects  of  muscular  exertion,  since  he  found  that 
among  miners  of  coal  and  lead  nearly  42  per  cent,  suffered 
from  motor  insufficiency. 

Persons  whose  calling  compels  them  to  reside  for  a  long 
time  in  hot  and  relaxing  climates  are  particularly  apt  to  suffer 
from  gastric  myasthenia,  and  children  who  are  bom  under 
these  conditions  frequently  develop  the  complaint  at  an  early 
period  of  life.  In  other  cases,  again,  the  disorder  appears  to 
arise  from  a  depressed  state  of  the  nervous  system,  and  it  is 


ETIOLOGY.  Ill 

therefore  unduly  frequent  among  those  whose  business  throws 
a  continual  strain  upon  the  mind,  who  are  exposed  to  constant 
worries  of  a  financial  or  domestic  nature,  or  who  suffer  from 
the  want  of  a  healthy  or  engrossing  occupation. 

The  prolonged  use  of  certain  drugs  is  occasionally  re- 
sponsible for  an  atonic  condition  of  the  digestive  tract.  Thus, 
the  injudicious  administration  of  mercury  and  iodide  of 
potassium  in  cases  of  syphilis,  of  digitalis  in  cardiac  disease, 
of  quinine  and  arsenic  in  malaria  or  nervous  disorders,  and 
of  salines  in  constipation,  is  particularly  injurious,  while 
painters  and  others-  who  constantly  absorb  small  quantities 
of  lead  usually  exhibit  signs  of  myasthenia  prior  to  the  onset 
of  the  more  striking  symptoms  of  plumbism.  The  abuse  of 
narcotics  is  another  frequent  though  often  unsuspected  cause 
of  the  complaint;  large  doses  of  bromides,  morphine,  codeine, 
sulphonal,  trional,  or  paraldehyde  being  often  responsible  for 
the  feeble  digestive  powers  that  are  so  often  associated  with 
persistent  insomnia.  Boracic  acid  and  borax  when  employed 
as  preservatives  of  milk  and  other  forms  of  food  exercise  an 
inhibitive  influence  upon  the  secretory  functions  of  the  stomach 
and  pancreas,  which  is  apt  to  be  followed  by  atony,  while  a 
similar  effect  is  sometimes  produced  by  the  artificial  colouring 
and  sweetening  agents  with  which  articles  of  food  are  so 
often  adulterated  at  the  present  day. 

Much  has  been  written  concerning  the  injurious  effects 
of  smoking  upon  the  processes  of  digestion,  and  Bouveret 
states  that  over-indulgence  in  the  habit  is  a  fruitful  cause  of 
myasthenia  gastrica.  On  the  other  hand,  careful  enquiries 
made  among  a  large  number  of  dyspeptics  do  not  corroborate 
our  preconceived  notions  on  the  subject;  and  as  far  back  as 
the  middle  of  last  century  Samuel  Fenwick  remarked  that 
"  in  no  part  of  these  enquiries  (into  the  causation  of  dyspepsia) 
have  I  been  more  surprised  than  at  the  results  obtained 
respecting  the  smoking  of  tobacco.  I  expected  no  difficulty 
in  proving  the  noxious  influence  of  the  habit  on  digestion;  and 


112  MYASTHENIA   GASTRICA. 

it  was  only  after  carefully  interrogating  the  facts  in  every  way 
that  I  abandoned  my  preconceived  opinion." 

In  the  first  place  as  regards  the  relative  incidence  of 
dyspepsia  among  smokers  and  non-smokers,  respectively,  my 
tables  show  among  healthy  men  who  had  habitually  smoked 
for  many  years,  49  per  cent,  had  never  suffered  from  dyspepsia 
and  51  per  cent,  were  more  or  less  subject  to  the  disorder; 
while  among  life-abstainers  from  the  weed  52  per  cent,  pos- 
sessed perfect  digestions  and  48  per  cent,  were  liable  to 
dyspepsia.  Again,  among  pipe-smokers  the  use  of  tobacco 
up  to  5  oz.  a  week  does  not  seem  materially  to  influence 
the  liability  to  indigestion.  Thus,  of  those  who  smoked  less 
than  three  ounces  a  week  51  per  cent,  suffered  from  dyspeptic 
symptoms  and  49  per  cent,  were  healthy;  while  of  those  who 
indulged  in  3  to  5  oz.  a  week,  56  per  cent,  were  dyspeptic  and 
44  per  cent,  were  healthy. 

As  in  the  case  of  other  drugs,  the  effects  of  nicotine  depend 
to  a  great  extent  upon  its  mode  of  administration  and  in- 
dividual idiosyncrasy.  Thus,  many  persons  suffer  no  ill 
effects  as  long  as  they  confine  themselves  to  some  special 
brand,  but  whenever  they  smoke  cigars  or  indulge  in  a  stronger 
form  of  tobacco,  they  are  at  once  attacked  by  indigestion. 
Inhalation  and  chewing  are  infinitely  more  injurious  to  the 
digestive  functions  than  oral  smoking,  and  these  habits  are 
often  the  unsuspected  cause  of  intractable  dyspepsia.  When 
smoking  gives  rise  to  indigestion,  the  gastric  disorder  is  more 
frequently  found  to  depend  upon  inflammation  or  hyper- 
chlorhydria  than  upon  primary  myasthenia,  the  relative 
proportions  of  the  three  complaints  in  every  hundred  cases 
of  "tobacco  dyspepsia"  being  approximately:  hyperacidity 
fifty-four,  gastritis  thirty,  and  myasthenia  sixteen. 

Finally,  myasthenia  of  an  acute  type  and  short  duration, 
occasionally  ensues  as  the  result  of  a  strong  emotion  or  of  a 
physical  shock,  such  as  a  blow  upon  the  abdomen  during  the 
period  of  gastric  digestion  or  cerebral  or  spinal  concussion. 


ETIOLOGY.  113 

Secondary  Myasthenia. — Myasthenia  of  secondary  origin  is 
far  more  common  than  the  primary  form  of  the  complaint. 
Almost  every  severe  case  of  anaemia  and  chlorosis  is  accom- 
panied by  an  enfeeblement  of  the  motor  power  of  the  stomach, 
and  nearly  18  per  cent,  of  the  cases  of  atonic  dyspepsia  which 
are  met  with  in  hospital  practice  in  London  occur  in  anaemic 
women.  Next  in  order  of  frequency  are  general  neurasthenia 
and  those  debihtated  constitutional  conditions  that  arise  from 
continued  suppuration,  leucorrhcea,  bleeding  piles,  menor- 
rhagia,  and  metrorrhagia,  while  in  both  sexes  the  practice  of 
excessive  masturbation  is  a  common  cause  of  the  disease. 
Chronic  constipation  is  almost  invariable  accompanied  by  an 
atonic  state  of  the  stomach,  and  no  permanent  rehef  is  af- 
orded  to  the  gastric  symptoms  until  the  action  of  the  bowels 
has  been  efficiently  regulated. 

Diseases  of  the  heart,  lungs,  and  liver  which  embarrass 
the  portal  circulation  and  give  rise  to  chronic  congestion  of 
the  gastrointestinal  tract  are  always  accompanied  by  in- 
dications of  myasthenia,  and  a  similar  effect  is  sometimes 
produced  by  chronic  enlargements  of  the  spleen. 

Chronic  gastritis,  whatever  be  its  cause,  is  almost  in- 
variably followed  by  atony,  and  in  many  instances  the  symp- 
toms of  the  two  complaints  alternate  regularly  with  one  another. 
In  such  cases  the  inflammation  of  the  mucosa  spreads  into 
the  muscular  coat  of  the  organ  along  the  connective  tissue 
that  surrounds  and  supports  the  bundles  of  muscle-fibres, 
and  its  organised  products  tend  not  only  to  hamper  the  con- 
tractility of  the  tissue,  but  may  lead  to  the  destruction  of  a 
considerable  portion  of  its  structure.  For  a  similar  reason 
chronic  ulcer,  cancer,  atrophy,  lardaceous  degeneration,  and 
other  organic  affections  of  the  stomach  are  always  attended 
by  myasthenia,  while  in  such  functional  disorders  of  the 
viscus  as  hypersecretion  and  neurasthenia,  as  well  as  in  cases 
of  gastroptosis  and  foreign  bodies,  many  of  the  most  prominent 
indications  of  the  complaint  are  due  to  the  coexistence  of 


114  MYASTHENIA   GASTRICA. 

atony.  Pulmonary  tuberculosis  is  attended  by  atony  of  the 
stomach  from  its  earliest  stage. 

Myasthenia  frequently  develops  during  the  convalescent 
period  of  such  specific  febrile  diseases  as  influenza,  measles, 
scarlatina,  pneumonia,  variola,  and  enteric  fever,  its  incidence 
being  often  encouraged  by  the  excess  of  milk  and  other  forms 
of  fluid  nourishment  with  which  the  patient  is  fed. 

Many  writers  have  noted  the  relationship  of  myasthenia 
gastrica  to  bihary  lithiasis,  and  my  own  experience  leads  me  to 
believe  that  more  than  one-third  of  the  cases  which  come 
under  treatment  for  gall-stones  have  previously  suffered  from 
atony  of  the  stomach  and  intestine. 

Disease  of  any  abdominal  organ  which  is  invested  by 
peritoneum  may  produce  myasthenia  by  a  process  of  reflex 
irritation.  In  most  instances  of  this  kind  the  mischief  is 
located  in  the  pelvic  viscera,  and  consists  of  displacement  of 
the  uterus,  inflammation  of  the  tubes  or  ovaries,  endometritis, 
or  a  prolapsed  and  tender  ovary.  In  like  manner  local 
peritonitis  in  any  part  of  the  abdominal  cavity  may  be  followed 
by  atony  of  the  stomach  (Wertheimer,  Hennart),  and  Peter 
has  even  observed  the  digestive  disorder  as  a  complication  of 
diphragmatic  pleurisy. 

Symptoms. — The  myasthenic  stomach  is  essentially  a  lazy 
stomach;  its  movements  are  sluggish,  the  food  becomes  slowly 
and  often  imperfectly  mixed  with  the  gastric  secretion,  and  the 
expulsion  of  the  semi-digested  material  into  the  intestine  is 
much  retarded.  If  due  allowance  be  made  for  these  peculiar- 
ities and  the  diet  be  carefully  regulated,  the  organ  will  continue 
to  discharge  its  functions  in  a  fairly  efficient  manner;  but  if 
any  attempt  be  made  to  impose  additional  work  upon  the 
viscus,  retention  and  decomposition  of  the  food  will  ensue, 
accompanied  by  indications  of  gastric  dilatation. 

As  in  the  case  of  many  other  disorders  of  the  digestive  organs 
a  considerable  period  may  elapse  between  the  establishment 
of  the  morbid   condition  and  the  occurrence  of  subjective 


SYMPTOMS.  115 

symptoms,  and  many  patients  will  consequently  exhibit  the 
physical  signs  of  gastric  myasthenia  for  months  or  even  years 
before  they  themselves  become  conscious  of  its  existence. 
The  non-appreciation  of  these  facts  has  led  to  much  confusion 
in  the  symptomatology  of  the  disease,  for  the  majority  of 
writers  either  make  no  distinction  between  myasthenia  and 
its  resultant  gastrectasis,  or  distinguish  two  varieties  of  the 
complaint — the  mild  and  the  severe — according  as  food 
stagnation  or  food  retention  constitutes  its  most  prominent 
feature.  In  order  to  fully  appreciate  the  protean  character 
of  the  complaint  it  is  necessary  to  consider  in  detail  the  three 
successive  stages  which  are  presented  by  the  disorder,  namely, 
the  latent  period,  the  stage  of  food  stagnation,  and  the  stage 
of  food  retention. 

(i)  The  Latent  Stage. — A  period  during  which  the 
characteristic  symptoms  of  myasthenia  are  absent  exists  in 
nearly  20  per  cent,  of  all  cases,  and  is  most  frequent  in  persons 
who  possess  a  highly  nervous  temperament  and  an  hereditary 
predisposition  to  the  complaint.  In  such  individuals  the 
appetite  continues  good  and  the  general  health  may  be  ex- 
cellent, but  at  irregular  intervals,  and  especially  when  they 
have  overeaten  themselves  or  have  indulged  in  some  article 
of  diet  that  habitually  disagrees,  they  suffer  from  a  sensation  of 
weight  or  oppression  at  the  chest,  which  comes  on  about  an 
hour  after  the  meal  and  is  accompanied  by  abdominal  dis- 
tention, flatulence,  and  languor.  These  symptoms  usually 
subside  within  a  few  hours  and  may  not  recur  for  many  weeks, 
but  as  a  rule  the  attacks  tend  to  make  their  appearance  at  short 
intervals  and  upon  the  least  provocation  until  eventually 
discomfort  after  meals  becomes  an  established  phenomenon. 
This  latent  stage,  which  usually  lasts  for  several  months  or 
even  years,  helps  to  explain  many  of  the  so-called  "acute" 
cases  of  gastric  myasthenia,  since  it  is  obvious  that  an  individual 
who  already  possesses  an  atonic  stomach,  although  uncon- 


Il6  MYASTHENIA   GASTRICA. 

scious  of  its  existence,  will  readily  become  the  subject  of 
definite  manifestations  if  he  be  exposed  to  physical  violence, 
severe  psychic  influences,  or  be  attacked  by  a  febrile  malady. 

(2)  The  Stage  of  Food  Stagnation. — Whether  the  dis- 
order be  preceded  by  a  prolonged  latent  period  or  commence 
in  a  more  abrupt  manner,  the  symptoms  that  portray  its  ex- 
istence are  always  characteristic  and  of  sufficient  importance 
to  attract  attention. 

Discomfort  during  the  period  of  gastric  digestion  is  usually 
the  most  constant  and  prominent  feature  of  the  case,  but  it 
varies  greatly  in  severity  under  different  conditions.  As  a 
rule,  it  commences  soon  after  the  ingestion  of  food,  and  reaches 
its  acme  within  an  hour  and  a  half,  after  which  it  either 
gradually  subsides  or  is  rapidly  removed  by  the  eructation 
of  a  large  quantity  of  gas.  The  sensation  is  usually  described 
as  one  of  weight,  fulness,  or  oppression,  and  not  only  affects 
the  upper  part  of  the  abdomen,  but  is  often  more  particularly 
felt  behind  the  sternum,  in  the  left  axilla,  or  between  the 
scapulae,  while  not  infrequently  the  skin  below  the  left  breast 
becomes  hyperaesthetic  or  is  the  seat  of  a  burning  pain. 
When  myasthenia  is  associated  with  gastroptosis  the  maximum 
discomfort  is  usually  located  in  the  umbilical  or  hypogastric 
region.  These  subjective  phenomena  are  almost  invariably  ac- 
companied by  abdominal  distention,  which  proves  so  uncom- 
fortable as  to  necessitate  loosening  of  the  clothing.  The  dis- 
comfort varies  in  degree  according  to  the  nature  and  quantity 
of  the  food,  and  in  mild  cases  may  only  be  experienced  after  the 
principal  meal  of  the  day.  Sooner  or  later,  however,  every  at- 
tempt to  partake  of  food  is  followed  by  distress,  and  the  only 
time  when  the  patient  is  free  from  discomfort  is  when  the 
stomach  is  empty. 

In  most  cases  it  may  be  observed  that  liquids  are  more 
deleterious  than  solids,  and  that  indulgence  in  a  cup  of  tea  or 
even  a  glass  of  water  is  followed  by  as  much  distention  as  a 


SYMPTOMS.  117 

moderate  meal.  In  like  manner,  soups,  broths,  or  a  diet  of 
milk  invariably  induce  an  abnormal  degree  of  distention, 
while  mineral  waters,  owing  to  the  gas  they  contain,  always 
occasion  severe  flatulence.  Another  characteristic  phenom- 
enon is  the  apparent  hmitation  of  the  capacity  of  the  stomach. 
Thus  many  subjects  of  gastric  myasthenia  will  remain  com- 
paratively free  from  indigestion  as  long  as  they  follow  a  rigid 
diet  and  carefully  restrict  the  amount  of  food  taken  at  each 
repast;  but  whenever  they  indulge  their  appetite  they  at  once 
experience  a  sense  of  overdistention  and  suffer  from  a  recru- 
descence of  all  their  former  symptoms.  Next  to  liquids, 
green  vegetables,  fruit,  and  farinaceous  substances  produce  the 
greatest  discomfort,  while  occasionally  overcooked  meat,  oily 
fish,  and  eggs  also  prove  difficult  of  digestion.  Distention  and 
eructation  in  the  early  morning  are  frequently  met  with  in 
cases  of  myasthenia  secondary  to  gastritis,  chlorosis,  or  gas- 
troptosis,  but  in  the  primary  form  of  the  complaint  these 
symptoms  are  rarely  experienced  when  the  stomach  is  devoid 
of  food.  Unless  the  disorder  is  complicated  by  hyperacidity 
or  hypersecretion,  the  further  indulgence  in  food  during  the 
persistence  of  the  gastric  symptoms  invariably  increases  the 
discomfort. 

Gaseous  eructations  occur  in  every  case  and  usually  con- 
stitute one  of  the  chief  causes  of  complaint.  As  a  rule,  the 
belchings  ensue  within  an  hour  of  a  meal,  and  are  especially 
severe  after  the  ingestion  of  fluids.  They  are  often  accom- 
panied and  occasionally  replaced  by  hiccough.  As  a  result 
of  the  eructation  small  quantities  of  semidigested  food,  of  a 
sweet  or  slightly  acid  taste,  are  forced  into  the  mouth  with  the 
escaping  gas.  Examination  of  the  eructated  gas  shows  that 
it  consists  for  the  most  part  of  atmospheric  air  that  has  been 
swallowed  with  the  food  mixed  with  small  quantities  of  carbon 
dioxide  and  hydrogen  generated  during  the  process  of  diges- 
tion. It  is  also  probable  that  the  carbonates  of  the  saliva 
yield  a  certain  quantity  of  carbonic  acid  gas  as  the  result  of 


Il8  MYASTHENIA   GASTRICA. 

their  decomposition  by  the  acid  gastric  secretion,  while  in 
some  instances,  at  any  rate,  the  patulous  condition  of  the 
pyloric  sphincter  permits  the  regurgitation  of  the  alkaline 
contents  of  the  intestine  which  undergo  a  similar  decomposi- 
tion. True  fermentation  of  the  food  seldom  occurs  at  this  stage 
of  the  disease. 

Vomiting  is  rarely  encountered,  but  sometimes  emesis  is 
excited  by  the  insertion  of  the  finger  into  the  throat  with  the 
object  of  securing  relief  from  indigestion.  Acid  regurgita- 
tions are  also  never  met  with  in  uncomplicated  cases. 

The  appetite  may  remain  unaffected  for  a  considerable 
time,  but  sooner  or  later  it  undergoes  a  gradual  diminution. 
The  desire  for  food  is  easily  satisfied,  and  although  the  patient 
may  sit  down  to  a  meal  with  every  expectation  of  enjoying  it, 
he  will  suffer  from  a  sense  of  satiety  after  a  single  course  or 
even  a  few  mouthfuls,  while  a  moderate  meal  gives  rise  to  a 
sense  of  repletion.  Occasionally  there  is  a  marked  distaste 
for  all  forms  of  food,  even  when  prolonged  abstinence  has 
given  rise  to  exhaustion,  or  special  avidity  is  displayed  toward 
such  articles  of  diet  as  sour  oranges,  lemons,  acid  drinks,  or 
pickles.  When  myasthenia  occurs  as  a  complication  of 
h}^eracidity  the  appetite  is  usually  increased,  and  many  of 
the  uncomfortable  sensations  that  ensue  during  the  course  of 
digestion  are  immediately  relieved  by  the  further  ingestion  of 
food. 

Thirst  never  exists,  and  in  most  instances  there  is  an  actual 
aversion  from  fluids,  owing  probably  to  the  fact  that  they 
increase  the  dyspeptic  symptoms. 

The  large  intestine  always  shares  the  myasthenic  state  of 
the  stomach,  with  the  result  that  constipation  is  an  invariable 
accompaniment  of  the  disorder.  The  stools  are  hard,  dry, 
colourless,  and  often  scybalous  in  appearance,  and  their 
evacuation  is  sometimes  followed  by  irritation  of  the  anus. 
Piles,  fissure,  and  slight  prolapse  of  the  rectum  are  also  occa- 
sionally encountered.     Offensive  evacuations  are  rarely  ob- 


SYMPTOMS.  119 

served  unless  the  diet  contains  an  excess  of  meat.  When 
gastroenteritis  compHcates  myasthenia,  attacks  of  diarrhoea 
are  apt  to  alternate  with  periods  of  constipation. 

The  habitual  stagnation  of  the  intestinal  contents  favours 
the  liberation  of  gases,  which  stretch  the  feeble  muscular  coat 
of  the  bowel  and  further  diminish  its  contractility;  hence 
circumscribed  swellings  often  make  their  appearance  in  the 
region  of  the  caecum,  hepatic,  splenic,  or  sigmoid  flexures,  and 
produce  a  sensation  of  fulness  or  dragging  accompanied  by 
noisy  borborygmi. 

At  other  times  distention  of  the  transverse  colon  gives  rise 
to  severe  pain  in  the  dorsolumbar  region  of  the  spine  or  at  the 
insertion  of  the  diaphragm  into  the  ribs,  which  may  simulate 
that  of  lumbago,  pleurisy  or  renal  colic. 

The  tongue  is  broad,  pale  and  flabby;  clean  or  slightly 
furred,  and  usually  indented  along  its  margins  by  the  teeth. 
The  inner  side  of  the  lips  and  gums  are  pallid  and  sometimes 
spongy  in  appearance;  the  tonsils  are  often  enlarged,  the  uvula 
and  pharynx  are  anaemic,  and  huskiness  of  the  voice  is  apt  to 
supervene  toward  evening  and  to  be  accompanied  by  constant 
efforts  to  clear  the  throat.  An  offensive  smell  of  the  breath 
and  skin,  rapid  decay  of  the  teeth,  painful  aphthous  ulceration 
of  the  tongue  and  gums,  and  attacks  of  salivation  are  also 
occasionally  encountered. 

At  first  the  general  health  is  well-preserved  and  there  is  no 
loss  of  weight;  but  in  the  course  of  time  the  patient  develops 
an  habitual  languor  and  difficulty  of  mental  concentration, 
and  exhibits  a  strong  disinclination  to  any  form  of  exertion, 
whether  mental  or  physical.  An  unconquerable  drowsiness 
is  often  experienced  after  meals,  which,  when  yielded  to,  affords 
a  heavy,  unrefreshing  sleep.  The  complexion  is  pale  and 
sallow,  there  are  dark  lines  beneath  the  eyes,  the  hands  and 
feet  are  cold  and  clammy,  and  profuse  perspirations  occur 
after  exercise  or  the  least  excitement. 

The  pulse  is  weak,  soft,  and  easily  compressible  and  is 


ISO  MYASTHENIA   GASTRICA. 

usually  unduly  slow  during  repose,  but  easily  excited  by 
movements  of  the  body.  Palpitation  is  a  constant  and 
troublesome  symptom  in  many  cases,  especially  in  neurotic 
and  neurasthenic  individuals.  It  is  most  pronounced  after 
meals,  and  is  frequently,  though  not  always,  traceable  to 
flatulent  distention  of  the  stomach  or  bowel.  Another 
phenomenon  with  which  it  is  often  associated  is  a  form  of 
dyspnoea  that  supervenes  during  the  first  hour  of  digestion. 
In  this  condition  the  patient  experiences  great  difficulty  of 
drawing  a  full  breath,  and  each  effort  to  inflate  the  lungs  is 
followed  by  a  long,  sighing  expiration.  Occasionally  a 
seizure  very  similar  to  asthma  (asthma  dyspepticum)  ensues 
after  the  principal  meal  of  the  day,  and  is  accompanied  by 
cardiac  irregularity,  cyanosis,  and  even  by  partial  collapse. 

The  urine  is  but  little  affected.  It  is  clear,  fairly  copious, 
and  deposits  phosphates  on  standing.  The  temperature  of 
the  body  is  usually  subnormal. 

Physical  Signs. — During  the  stage  of  food  stagnation  the 
stomach  is  not  dilated,  and  since  there  is  no  obstruction  to  the 
passage  of  its  contents  into  the  duodenum  the  usual  indi- 
cations of  gastric  hypertrophy  are  absent.  Consequently, 
the  various  methods  of  determining  the  size  of  the  organ  fail 
to  indicate  any  permanent  enlargement,  and  no  peristaltic 
movements  are  visible  upon  inspection  of  the  abdomen. 
It  is  only  when  the  stomach  is  dislocated  downward  or 
distended  with  gas  that  its  outlines  become  apparent  to  the 
naked  eye. 

The  chief  signs  of  gastric  myasthenia  at  this  stage  of  the 
complaint  are:  (i)  the  persistence  of  splashing  during  digestion; 
(2)  the  retention  of  food  beyond  the  ordinary  physiological 
Hmit;  (3)  an  undue  distensibility  of  the  gastric  walls. 

(i)  Much  misconception  exists  concerning  the  significance 
of  splashing  or  "clapotage"  on  palpation  of  the  stomach, 
some  writers  believing  it  to  be  pathognomonic  of  myasthenia 
while  others  attach  little  or  no  importance  to  its  presence. 


PHYSICAL    SIGNS.  121 

It  will  be  interesting,  therefore,  to  notice  a  few  facts  with 
regard  to  this  phenomenon. 

Splashing  sounds  elicited  by  manipulation  of  the  abdomen 
are  due  to  the  presence  of  gas  and  liquid  in  a  cavity  or  hollow 
viscus.  They  are  accordingly  met  with  in  cases  of  subdia- 
phragmatic abscess  when  the  sac  contains  both  pus  and  gas, 
in .  gastric  dilatation,  in  gastroptosis  accompanied  by  myas- 
thenia, in  myasthenia  of  the  stomach  during  the  entire  period 
of  digestion,  and  in  atony  of  the  colon  if  the  intestine  happens 
to  contain  an  excess  of  fluid.  In  healthy  individuals  the 
stomach  splash  can  sometimes  be  detected  within  ten  minutes 
of  the  ingestion  of  half  a  pint  of  fluid,  and  less  frequently  at 
Ih'e  end  of  the  digestion  of  a  large  meal,  when  a  small  amount 
of  liquid  chyme  still  remains  in  the  organ.  At  aU  other 
times  the  retraction  of  the  stomach  upon  its  contents  is  too 
firm  to  allow  the  phenomenon  to  occur,  while  the  liquid 
imbibed  with  the  food  rapidly  finds  an  exit  into  the  duodenum. 
Again,  under  pathological  conditions  there  is  a  great  difference 
in  the  ease  with  which  the  splash  can  be  obtained;  in  some 
instances  deep  palpation  and  repeated  efforts  being  required 
to  elicit  the  sound,  while  in  others  the  lightest  stroke  of  the 
finger  or  the  least  movement  of  the  patient's  body  is  sufl&cient 
to  produce  it.  The  area  of  the  abdomen  over  which  the 
sound  can  be  produced  is  also  a  matter  of  importance,  since 
in  healthy  persons  who  have  just  imbibed  a  glass  of  effervescing 
water  the  succussion  can  only  be  detected  by  palpation  over 
the  upper  epigastrium  and  left  hypochondrium,  while  in  cases 
of  dilated  stomach  the  sound  may  be  audible  over  the  greater 
portion  of  the  abdomen,  the  lowest  point  at  which  it  can  be 
obtained  marking  the  position  of  the  great  curvature. 

Finally,  a  splash,  exactly  similar  to  that  produced  in  the 
stomach,  occasionally  arises  from  the  presence  of  gas  and 
liquid  in  the  transverse  colon.  This  fact,  which  was  often 
commented  upon  in  the  writings  of  Samuel  Fenwick,  Lebert, 
and  Wilson  Fox,  has  been  more  recently  insisted  upon  by 


122  MYASTHENIA   GASTRICA. 

Chomele;  while  Debove  and  Remond  have  recorded  cases  in 
which  a  succussion  sound  was  present  although  the  stomach 
had  been  emptied  by  a  tube. 

From  these  considerations  it  follows  that  a  gastric  splash,' 
which  can  be  obtained  one  hour  or  more  after  a  meal,  is  a 
certain  indication  of  impairment  of  the  muscular  power  of 
the  stomach,  the  duration  of  the  phenomenon  and  the  ease 
with  which  it  can  be  demonstrated  being  roughly  propor- 
tionate to  the  degree  of  motor  insufficiency.  In  every  case 
of  myasthenia,  whether  primary  or  secondary,  clapotage  may 
be  observed  from  the  commencement  of  the  meal  until  after 
the  expiration  of  three  or  more  hours,  and  in  severe  instances 
it  may  only  be  in  the  early  morning  that  manipulation  of  the 
epigastrium  fails  to  produce  the  characteristic  sound. 

(2)  Stagnation  of  the  Gastric  Contents. — Although  many 
methods  have  been  devised  to  demonstrate  the  existence  of 
motor  insufficiency,  the  old  procedure  of  Leube,  which  tests 
the  time  occupied  by  digestion,  is  still  the  most  convenient  and 
serviceable.  When  a  healthy  person  is  supplied  with  a  meal 
consisting  of  half  a  pint  of  broth,  6  oz.  of  beefsteak,  i^  oz. 
of  mashed  potato,  and  a  roll,  the  stomach  is  found  to  be  quite 
empty  at  the  expiration  of  seven  hours.  In  cases  of  motor 
insufficiency,  on  the  other  hand,  the  passage  of  a  tube  seven 
hours  after  the  administration  of  such  a  test-meal  will  show 
that  the  stomach  still  contains  undigested  food,  the  amount  of 
which  is  directly  proportionate  to  the  degree  of  muscular 
failure.  This  evidence  of  food  stagnation  is  forthcoming  in 
every  instance  of  gastric  myasthenia,  and  in  severe  examples, 
the  stomach  is  only  empty  in  the  early  morning.  In  every 
case  it  is  advisable  to  wash  out  the  organ  before  the  admin- 
istration of  the  test-dinner,  lest  it  contain  the  residue  of  some 
previous  meal. 

Ewald  and  Sievers  recommend  the  administration  of  salol 
as  a  test  of  the  motor  power  of  the  stomach,  since  this  substance 
is  unaffected  by  the  gastric  juice,  but  is  rapidly  split  up  by  the 


PHYSICAL    SIGNS.  1 23 

alkaline  fluids  of  the  intestine  into  salicylic  acid  and  phenol, 
the  former  of  which  is  eliminated  by  the  kidney  and  can  easily 
be  detected  in  the  urine.  When  15  grains  of  salol  enclosed 
in  a  cachet  are  administered  to  a  healthy  individual  the 
characteristic  reaction  of  the  urine  (violet  colour  on  the 
addition  of  neutral  chloride  of  iron  solution)  can  be  detected 
within  thirty  to  seventy-five  minutes.  If  the  reaction  is  de- 
layed beyond  the  latter  period  it  is  obvious  that  the  salol  did 
not  escape  from  the  stomach  within  the  normal  time.  Many 
writers  have  taken  exception  to  this  method  (Decker,  Riegel, 
Reale  and  Grande,  Wotitsky),  and  Stein  has  shown  that  an 
excess  of  mucus  in  the  stomach  is  capable  of  decomposing  the 
salol,  while  occasionally  the  salt  is  absorbed  by  the  gastric  wall 
and  decomposed  in  the  circulation. 

Huber  employs  the  salol  test  for  the  purpose  of  determining 
the  length  of  time  during  which  salicyhc  acid  persists  in  the 
urine.  Thus  he  has  found  that  in  healthy  subjects  the  reaction 
disappears  after  twenty-seven  hours,  while  in  cases  of  motor 
insufficiency  the  violet  colour  may  be  recognised  after  the  expi- 
ration of  thirty-six  hours  or  longer.  Winckler  and  Stein  prefer 
iodipin  to  salol,  since  it  is  rapidly  decomposed  in  the  intestine 
with  the  liberation  of  free  iodine  which  is  eliminated  in  the 
saliva.  Under  normal  conditions  the  iodine  can  be  detected 
in  the  saliva  fifteen  minutes  after  the  iodipin  has  been  swal- 
lowed, whereas  in  cases  of  diminished  gastric  motility  it  may 
not  appear  for  several  hours.  It  would,  therefore,  seem 
that  if  free  iodine  cannot  be  detected  in  the  sahva  at  the  end 
of  forty-five  minutes  some  degree  of  motor  insufficiency  exists. 
The  oil  methods  of  Klemperer  and  of  Mathieu  and  Hallot 
have  a  certain  amount  of  scientific  interest,  but  as  they  involve 
considerable  trouble  and  discomfort  to  the  patient  they  are 
devoid  of  practical  value. 

(3)  Undue  Distensihility  of  the  Gastric  Walls. — This  ab- 
normal condition,  the  existence  of  which  can  be  surmised  from 
the  flaccidity  of  the  viscus  and  the  imperfect  manner  in  which 


124  MYASTHENIA   GASTRICA. 

it  contracts  upon  its  contents,  may  be  demonstrated  by  a 
method  introduced  by  Dehio.  If  the  outlines  of  the  stomach 
be  carefully  determined  when  the  subject  is  in  the  erect  posi- 
tion, it  is  found  that  after  drinking  a  tumblerful  of  water  the 
lower  border  of  the  organ  will  descend  to  a  spot  in  the  median 
line  of  the  abdomen  about  4^  inches  below  the  lower  end 
of  the  sternum.  After  a  second  glass  it  is  usually  i  inch  lower 
than  after  the  first;  a  third  glass  will  depress  it  another  inch, 
and  a  fourth  i  inch  further.  Penzoldt,  Weil,  and  other  ob- 
servers state  that  2  quarts  of  water  rarely  depress  the  great 
curvature  to  the  level  of  the  umbilicus.  In  myasthenia,  the 
atonic  state  of  the  gastric  wall  renders  the  viscus  more  easily 
distensible  than  under  normal  circumstances,  and  consequently 
a  single  glass  of  water  will  usually  depress  the  lower  border 
of  the  stomach  to  the  same  extent  as  two  glasses  in  a  healthy 
person,  while  not  infrequently  a  quart  will  be  found  to  cause 
the  great  curvature  to  sink  below  the  level  of  the  umbilicus. 
The  same  phenomenon  is  observed  when  air  is  pumped  into 
the  organ  or  when  the  viscus  is  distended  with  carbonic  acid, 
as  under  both  these  conditions  a  comparatively  slight  rise  of 
intragastric  pressure  produces  a  disproportionate  degree  of 
distention. 

Chemical  examination  of  the  contents  of  the  stomach  after 
a  test-meal  shows  no  constant  deviation  from  the  state  of 
health.  In  most  cases  the  secretion  of  hydrochloric  acid  is 
either  normal  or  somewhat  increased,  and  in  many  of  the 
secondary  varieties  of  myasthenia  hyperchlorhydria  is  found 
to  exist.  It  may  also  be  demonstrated  that  the  secretion  is 
more  prolonged  than  usual  owing  to  the  protracted  evacuation 
of  the  chyme.  Lactic  acid  and  other  products  of  fermentation 
are  absent. 

3.  The  Stage  of  Food  Retention. — Long-continued 
stagnation  of  food  in  the  stomach  exercises  a  serious  influence 
upon  the  gastric  functions.     The  prolongation  of   digestion 


PHYSICAL    SIGNS.  12$ 

curtails  the  periods  of  rest  and  tends  still  further  to  exhaust 
the  muscular  structure,  while  the  delay  in  the  transmission  of 
the  chyme  into  the  duodenum  favours  the  development  of 
the  various  forms  of  fermentation,  with  the  result  that  the 
viscus  becomes  distended  by  gases  which  stretch  its  enfeebled 
walls  and  lead  to  dilatation  of  its  cavity.  It  follows,  therefore, 
that  myasthenia  gastrica  possesses  an  inherent  tendency  to 
terminate  in  dilatation  of  the  stomach.  In  all  cases  the  de- 
velopment of  gastrectasis  is  a  gradual  process,  and  the  symp- 
toms of  the  second  stage  of  myasthenia  merge  almost  imper- 
ceptibly into  those  of  food  retention. 

In  this,  the  terminal  phase  of  the  complaint,  the  discomfort 
which  was  formerly  experienced  after  meals  becomes  ac- 
centuated and  also  alters  somewhat  in  character.  Instead  of 
liquids  being  chiefly  responsible  for  the  sense  of  weight  and 
fulness  in  the  epigastrium,  the  patient  notices  that  solid  and 
semisolid  articles  of  diet  occasion  genuine  pain  in  the  chest, 
abdomen  and  back,  and  that  a  few  mouthfuls  will  often 
destroy  any  desire  for  food  which  may  previously  have  existed. 
At  the  same  time  additional  distress  is  caused  by  severe  dis- 
tention of  the  stomach,  which  produces  oppression  at  the  chest, 
dyspnoea  on  exertion,  palpitation,  and  sometimes  giddiness 
and  faintness,  for  the  relief  of  which  it  may  be  necessary  to 
loosen  the  clothing  and  to  seek  a  recumbent  posture.  Gaseous 
eructations  accompany  these  manifestations  of  distress,  and 
although  they  afford  a  certain  amount  of  relief,  the  desire 
to  expel  gas  from  the  stomach  may  continue  urgent  for  several 
hours.  As  the  acid  products  of  fermentation  accumulate  in  the 
stomach,  severe  epigastric  pain,  somewhat  similar  to  that  met 
with  in  hyperchlorhydria,  may  be  experienced,  accompanied 
by  eructations  of  an  acid  fluid  which  causes  scalding  pain  in  the 
pharynx  and  behind  the  sternum  with  an  unpleasant  taste  in 
the  mouth.  The  appetite  is  poor  and  becomes  progressively 
less  and  is  often  accompanied  by  severe  thirst.  Insomnia  is 
commonly  present  at  this  stage  of  the  complaint,  and  in  the 


126  MYASTHENIA   GASTRICA. 

early  morning  the  patient  feels  weak,  tired,  and  depressed  and 
may  suffer  from  heavy  frontal  headache. 

Nausea  varies  in  severity  in  different  cases,  in  some  being 
a  constant  and  distressing  symptom  while  in  others  little  or  no 
sense  of  sickness  is  experienced  even  prior  to  an  attack  of 
emesis.  The  most  important  indication  of  the  development 
of  gastrectasis  is  vomiting,  which  exists  to  a  greater  or  lesser  de- 
gree in  every  case.  At  first  the  accumulation  of  undigested  and 
fermenting  food  is  relieved  every  third  or  fourth  day  by  a 
copious  sickness  which  affords  great  relief  to  the  other  symptoms, 
but  in  the  course  of  time  the  vomiting  tends  to  become  more 
frequent  and  to  occur  three  or  four  hours  after  the  principal 
meal  of  the  day.  It  differs  from  that  which  arises  from 
pyloric  obstruction  in  that  it  rarely  ensues  during  the  night, 
is  less  copious,  and  often  fails  to  empty  the  stomach  completely. 
The  ejecta  consist  of  a  brownish,  pultaceous,  sour-smelling 
material,  which  imparts  a  sour  or  bitter  taste  to  the  mouth, 
and  is  often  glutinous  owing  to  its  admixture  with  mucus. 
As  in  other  varieties  of  gastrectasis,  the  vomit  often  separates 
on  standing  into  three  layers,  the  uppermost  of  which  is  frothy, 
the  middle  opaque,  while  the  lowest  consists  of  undigested 
food  which  may  present  a  seething  appearance  owing  to  the 
rapid  evolution  of  gas. 

As  a  result  of  the  maldigestion  of  the  food  and  the  frequent 
evacuation  of  the  stomach,  emaciation  is  a  constant  feature 
of  the  complaint,  and  the  body  weight  may  diminish  by  a 
pound  or  more  each  week.  The  skin  also  becomes  dry  and 
harsh,  dandruff  appears  on  the  scalp,  and  the  hair  persistently 
falls  out.  The  intestinal  functions  are  always  deranged  sooner 
or  later  owing  to  the  entrance  into  the  bowel  of  undigested 
and  fermenting  food,  with  the  result  that  the  patient  suffers 
frequently  from  colic  or  complains  of  a  sense  of  weight  and 
fulness  in  the  lower  part  of  the  abdomen  accompanied  by 
constipation  and  the  passage  of  foul  gas.  In  long-standing 
cases  the  excreta  are  pale,  dry,  scybalous,  and  coated  with 


PHYSICAL   SIGNS.  1 27 

mucus,  while  at  intervals  a  form  of  spurious  diarrhoea  super- 
venes, in  which  the  motions  are  entirely  composed  of  slime 
and  yeasty  material.  In  rare  instances  membranous  colitis 
ultimately  develops. 

Owing  to  deficient  absorption  from  the  stomach  and  the 
frequent  emesis,  the  urine  is  diminished  in  amount  and  pos- 
sesses a  higher  specific  gravity  than  normal.  Both  the  total 
acidity  and  the  output  of  chlorides  are  markedly  decreased, 
and  a  copious  deposit  of  phosphates  occurs  on  standing. 
When  vomiting  is  an  urgent  symptom  the  breath  and  the 
urine  often  smell  of  acetone,  and  diacetic  acid  may  sometimes 
be  detected  in  the  latter. 

Almost  every  organ  of  the  body  suffers  more  or  less  severely 
from  malnutrition  and  the  effects  of  toxic  absorption.  Anaemia 
is  invariably  present;  the  complexion  is  muddy  and  un- 
healthy, while  not  infrequently  the  skin  of  the  trunk  and 
extremities  presents  an  erythematous  or  acneform  eruption 
or  is  affected  by  eczema  or  pityriasis.  The  thickening  and 
enlargement  of  the  second  phalangeal  joints,  which  gives 
rise  to  pain  and  stiffness  of  the  fingers,  is  considered  by 
Bouchard  to  be  characteristic  of  toxic  absorption  from  the 
stomach. 

Few  sufferers  from  this  gastric  disorder  escape  symptoms 
referable  to  the  heart  and  circulation,  the  most  conspicuous  of 
which  are  attacks  of  palpitation  after  meals,  irregularity  of  the 
cardiac  action,  or  tachycardia.  In  other  cases  asthmatic 
seizures  supervene  after  meals  or  attacks  of  choking  and 
suffocation  occur  during  the  night.  When  the  colon  becomes 
inflamed  other  mucous  membranes  are  apt  to  be  affected  in  a 
similar  manner,  and  the  symptoms  of  cystitis,  cysto-pyelitis, 
pharyngitis,  and  postnasal  catarrh  may  prove  so  troublesome 
as  to  distract  attention  from  the  original  complaint.  The 
hepatic  functions  are  always  disturbed  by  the  presence  in  the 
portal  system  of  the  poisonous  products  of  food  decomposition, 
so  that  in  addition  to  the  unhealthy  aspect  of  the  stools. 


128  MYASTHENIA   GASTRICA. 

heaviness  or  pain  in  the  right  hypochondrium,  a  metallic 
taste  in  the  mouth,  an  icteric  tinge  of  the  conjunctivae  and 
skin,  and  haemorrhoids  add  considerably  to  the  other  sources 
of  discomfort.  Finally,  nervous  phenomena  are  rarely  absent, 
and  most  patients  complain  at  one  time  or  another  of  drowsi- 
ness and  apathy  after  meals,  headache,  impairment  of  memory, 
and  general  lassitude,  while  in  some  cases  tinnitus,  difficulty 
of  speech,  weight  and  numbness  of  the  extremities,  muscular 
cramps,  tetany,  or  even  slight  convulsions  may  occasion 
anxiety  by  simulating  an  organic  affection  of  the  brain  or  cord. 

Physical  Signs. — Inspection  of  the  abdomen  never 
reveals  active  peristalsis  of  the  stomach,  but  the  enlarged  viscus 
may  sometimes  be  detected  by  an  abnormal  protuberance 
of  the  epigastrium  and  umbilical  regions.  Occasionally  the 
swelling  undergoes  rhythmic  augmentation  and  diminution 
as  the  gases  which  are  generated  in  the  organ  accumulate 
or  are  discharged  into  the  bowel  or  eructated,  and  under 
these  circumstances  auscultation  of  the  stomach  will  reveal 
a  variety  of  bubbling  and  sizzling  sounds  produced  by  the 
gas  escaping  from  the  fermenting  chyme. 

Artificial  distention  and  auscultatory  percussion  show 
the  stomach  to  be  somewhat  enlarged  and  often  dislocated 
downward  owing  to  its  increased  weight,  the  lower  border 
of  the  viscus  reaching  to  the  level  of  or  below  the  umbilicus 
and  the  pyloric  antrum  to  the  right  of  the  median  line  of  the 
abdomen.  As  in  the  second  stage  of  the  complaint,  splashing 
sounds  may  be  elicited  during  the  whole  period  of  digestion, 
while  owing  to  prolonged  retention  of  food  succussion  may 
sometimes  be  obtained  in  the  early  morning. 

The  pathognomonic  sign  of  motor  insufficiency  is  the 
presence  of  food  in  the  organ  in  the  early  morning  after  a 
test-supper.  In  order  to  obtain  the  most  accurate  informa- 
tion upon  this  point,  the  stomach  should  be  washed  out  at 
7  P.M.,  after  which  the  patient  takes  a  meal  composed  of 
soup,  meat,  bread,  and  potato.     Lavage  is  again  performed 


PHYSICAL    SIGNS.  1 29 

at  7  o'clock  on  the  following  morning,  when  the  amount 
of  undigested  food  that  is  evacuated  affords  an  accurate 
estimate  of  the  degree  of  muscular  insufficiency.  Some 
writers  lay  much  stress  upon  the  so-called  "water  test"  for 
myasthenia,  which  consists  of  the  administration  of  a  pint  of 
cold  water  and  the  evacuation  of  the  stomach  after  the  lapse  of 
two  hours.  When  the  pylorus  is  obstructed,  the  fluid  is 
rapidly  squeezed  by  the  hypertrophied  viscus  into  the  duo- 
denum, although  it  is  unable  to  dispatch  its  solid  contents 
with  a  like  celerity;  but  in  myasthenia  the  feeble,  flabby  walls 
of  the  organ  remain  practically  inert  under  the  stimulus  of 
liquids,  and  consequently  the  greater  part  of  the  water  may  be 
recovered  after  the  lapse  of  two  hours. 

Chemical  Analysis. — The  contents  of  the  stomach  obtained 
by  a  tube  or  by  vomiting  usually  present  a  sour,  offensive, 
or  rancid  odour,  and  on  standing  separate  into  the  three  layers 
that  are  so  characteristic  of  fermentation.  An  examination 
of  the  fermentative  activity  of  the  mixture  is  of  some  importance 
in  diagnosis,  and  is  conducted  in  the  following  manner:  A 
test-tube  is  completely  filled  with  the  chyme  or  vomit  and  its 
mouth  securely  plugged  with  an  india-rubber  cork  through 
which  passes  a  bent  glass  tube.  The  apparatus  is  then 
inverted  in  a  beaker  and  placed  in  an  incubator  at  a  tem- 
perature of  100°  F.  The  insertion  of  the  cork  squeezes  some 
of  the  material  into  the  glass  tube  and  thus  renders  the  test- 
tube  free  from  air.  When  fermentation  occurs,  bubbles  of 
gas  develop  and  rise  to  the  top  of  the  tube,  thereby  causing 
the  semi-liquid  material  to  overflow  into  the  beaker.  If  this 
process  can  be  observed  within  two  or  three  hours  the  degree 
of  retention  and  fermentation  is  considerable;  but  if  twelve 
or  more  hours  elapse  the  condition  is  proportionately  slight. 
On  analysis  the  gas  is  found  to  consist  of  a  mixture,  in  varying 
proportions,  of  hydrogen,  carbonic  acid,  and  nitrogen,  with 
sometimes  lesser  amounts  of  marsh  gas  and  sulphuretted 
hydrogen.  The  results  of  a  test  meal  vary  somewhat  in 
9 


130  MYASTHENIA   GASTRICA. 

different  cases.  If  secondary  gastritis  is  absent,  free  hydro- 
chloric acid  in  diminished  amount  may  be  determined,  but  in 
long-standing  cases  chronic  inflammation  of  the  stomach 
almost  invariably  exists,  with  the  result  that  free  acid  is 
wanting,  the  combined  acid  markedly  diminished,  while 
traces  of  lactic  and  other  organic  acids  may  occasionally  be 
detected.  The  activity  of  the  special  ferments  varies  directly 
with  the  secretion  of  hydrochloric  acid.  Microscopical 
examination  of  the  sediment  shows  epithelial  and  food  debris, 
torulae,  numerous  bacteria,  and,  in  rare  instances,  sarcinae. 

Diagnosis. — Myasthenia  gastrica  seldom  presents  any 
serious  difiGiculties  of  diagnosis  if  the  clinical  history  and 
physical  signs  of  the  complaint  are  carefully  investigated. 
The  relative  severity  of  the  dyspepsia  after  the  ingestion  of 
fluids,  and  the  distention,  discomfort,  and  gaseous  eructations 
which  ensue  immediately  after  meals,  will  always  suggest  an 
enfeeblement  of  the  gastric  walls  rather  than  an  abnormality  of 
secretion,  while  the  persistence  of  splashing  during  the  period 
of  digestion,  the  undue  distensibility  of  the  stomach  and  the 
retention  of  food  beyond  the  usual  physiological  limit  are 
pathognomonic  of  the  complaint.  Gastrectasis  only  ensues  in 
very  chronic  cases,  and  in  this  condition  the  comparative 
infrequency  of  vomiting,  the  stagnation  of  fluids,  and  the 
absence  of  other  indications  of  pyloric  obstruction  serve  to 
distinguish  the  complaint  from  the  motor  insufficiency  of 
pyloric  stenosis. 

Myasthenia  accompanied  by  stagnation  of  food  is  apt  to  be 
confounded  with  neurasthenia  gastrica,  gastroptosis,  and 
chronic  gastritis. 

In  both  neurasthenia  and  myasthenia  gastrica  the  dyspeptic 
symptoms  may  be  very  similar  in  character,  but  in  the  former 
they  vary  in  severity  from  day  to  day  even  when  the  same  food 
is  taken,  are  rarely  proportionate  to  the  size  of  the  meal,  and 
are  most  severe  after  the  ingestion  of  solids,  while  in  myasthenia, 
liquids  and  large  meals  are  productive  of  the  greatest  dis- 


DIAGNOSIS.  131 

comfort.  In  neurasthenia,  psychical  influences  exert  a  dis- 
proportionate effect  upon  the  digestion;  the  abdominal 
plexuses  are  tender  to  pressure;  headache,  insomnia  general 
debility,  and  other  signs  of  general  neurasthenia  are  present, 
and  the  motor  and  secretory  functions  of  the  stomach  may  be 
normal.     (Chapter  V.) 

Gastroptosis  is  easily  recognised  by  its  physical  signs :  The 
lesser  curvature  descends  in  the  abdomen  and  the  other 
viscera  are  also  usually  displaced.  When,  as  is  frequently 
the  case,  the  condition  is  accompanied  by  myasthenia,  splash- 
ing sounds  and  the  signs  of  stagnation  of  food  are  also  present. 
(Chapter  VI.) 

Chronic  gastritis  is  usually  due  either  to  direct  irritation  of 
the  gastric  mucosa  or  to  disease  of  some  other  important  organ 
of  the  body;  its  mode  of  causation  therefore  is  notably  different 
from  that  of  myasthenia.  Moreover,  except  at  an  advanced 
stage,  the  inflamed  stomach  is  not  accompanied  by  motor 
insufficiency,  the  organ  is  not  increased  in  size,  and  there  is  no 
abnormal  splashing.  The  acid  secretion  is  diminished,  after 
a  test-meal  mucus  is  present  in  excess,  and  a  pint  of  water 
is  easily  evacuated  into  the  duodenum  within  two  hours. 

Myasthenia  with  retention  of  food  has  to  be  distinguished 
from  hypersecretion  and  stenosis  of  the  pylorus. 

The  symptoms  of  hypersecretion  are  much  more  severe 
than  those  of  simple  myasthenia;  pain  may  be  excessive,  acid 
regurgitations  are  seldom  absent,  vomiting  is  very  apt  to 
occur  each  night,  while  emaciation  is  often  profound  though 
the  appetite  remains  good.  The  stomach  is  usually  dilated, 
and  in  most  instances  a  certain  degree  of  pyloric  stenosis 
exists.  The  first  point  which  requires  elucidation  is  the  nature 
of  the  gastric  contents  in  the  early  morning,  and  for  this 
purpose  the  stomach  is  washed  out  in  the  evening  and  no  food 
allowed  during  the  night.  If  continuous  secretion  exists 
the  passage  of  a  tube  in  the  morning  before  breakfast  will 
evacuate  a  considerable  quantity  of  fluid  which  affords  the 


132  MYASTHENIA  GASTRICA. 

characteristic  reactions  of  gastric  juice.  When  lavage  is  not 
performed  overnight,  the  stomach  may  be  found  to  contain 
a  certain  amount  of  undigested  food  mixed  with  an  excess  of 
acid  secretion.  The  history  of  the  case,  combined  with  this 
demonstration  of  continuous  secretion  is  sufficient  to  determine 
the  diagnosis. 

Pyloric  stenosis  may  be  due  to  carcinoma,  cicatricial 
contraction,  or  to  the  pressure  of  a  tumour.  Obstruction  from 
carcinoma  presents,  during  its  early  stages,  many  of  the 
features  of  primary  myasthenia,  and  is  therefore  very  apt  to 
be  mistaken  for  the  functional  disorder.  It  may  be  observed, 
however,  that  in  the  organic  complaint  the  flatulence  and 
discomfort  are  chiefly  experienced  after  soHds,  and  are  at  first 
relieved  by  a  liquid  diet;  while  the  reverse  obtains  in  cases  of 
primary  myasthenia.  The  loss  of  flesh  and  strength  are 
disproportionate  to  the  apparent  disturbance  of  the  digestion; 
vomiting  is  frequent  and  complete,  and  the  progress  of  the 
complaint  is  comparatively  rapid.  Hypertrophy  of  the 
stomach  is  shown  by  the  presence  of  visible  peristalsis;  a  test- 
meal  exhibits  few  signs  of  digestion  and  is  largely  mixed  with 
mucus,  and  there  is  a  tendency  for  free  hydrochloric  acid  to 
disappear  and  to  be  replaced  by  lactic  acid.  It  may  also  be 
shown  that  there  is  no  undue  distensibility  of  the  gastric  walls, 
while  the  water  test  proves  that  fluid  is  soon  passed  into  the 
duodenum. 

Prognosis. — This  varies  according  to  the  causation  and 
severity  of  the  disease.  In  the  acute  variety,  the  symptoms 
usually  subside  under  careful  treatment  within  ten  days  or  a 
fortnight,  but  since  in  most  instances  the  myasthenia  was 
latent  previous  to  its  sudden  manifestation,  subsequent 
attacks  are  always  liable  to  supervene  from  apparently 
trifling  causes.  Myasthenia  with  stagnation  of  food  represents 
about  86  per  cent,  of  the  cases  met  with  in  practice,  and  if 
properly  treated  about  one-half  of  these  terminate  in  complete 
recovery.     In  the  other  50  per  cent,  the  symptoms  undergo 


TREATMENT.  1 33 

remissions  for  periods  varying  from  a  few  weeks  to  several 
months,  but  the  tendency  to  relapse  is  never  entirely  lost,  and 
in  many  instances  a  change  of  climate,  an  increase  of  diet,  an 
attack  of  constipation  or  of  a  febrile  disorder,  or  a  strong 
emotion  will  at  once  occasion  a  renewal  of  all  the  former 
symptoms.  In  about  14  per  cent,  of  all  cases  the  complaint 
gradually  drifts  into  the  stage  of  food  retention  accompanied 
by  the  signs  of  dilatation  of  the  stomach.  The  prognosis  in 
this  form  is,  in  my  opinion,  generally  unfavourable,  and  I  can 
bring  to  mind  very  few  cases  which  can  be  said  to  have  been 
cured,  and  even  in  these  it  is  probable,  owing  to  the  per- 
sistence of  the  physical  signs,  that  the  symptoms  merely 
became  latent.  As  long  as  the  retention  remains  slight  in 
degree  and  the  general  nutrition  is  well  maintained,  it  is 
usually  possible  by  careful  treatment  to  transform  the  case 
into  the  stagnation  type  of  the  complaint;  but  when  the  pa- 
tient has  already  lost  much  flesh  or  when  secondary  gastro- 
enteritis has  supervened,  an  amelioration  of  the  symptoms  is 
the  only  result  which  can  be  confidently  predicted. 

Gastric  myasthenia  often  precedes  phthisis  in  persons  who 
are  predisposed  to  that  disease,  and  is  an  almost  invariable 
sequela  of  arrested  pulmonary  tuberculosis. 

"  Treatment. — Prophylaxis. — The  fact  that  myasthenia 
is  very  apt  to  develop  during  convalescence  from  a  febrile 
malady  and  in  the  course  of  certain  debilitating  diseases 
renders  it  important  that  special  precautions  should  be  taken 
to  conserve  the  motor  power  of  the  stomach.  The  overfeeding 
with  fluid  forms  of  nourishment  which  is  so  commonly  adopted 
under  these  conditions  stretches  the  already  enfeebled  walls 
of  the  viscus  and  is  often  the  exciting  cause  of  the  malady. 
For  this  reason  milk  should  be  mixed  with  barley-  or  lime- 
water  and  be  administered  in  doses  not  exceeding  6  oz.  at  a 
time,  while  jellies,  meat  juices,  and  meat  essences  are  to  be 
preferred  to  the  home-made  beef  tea,  soups,  and  broths,  the 
nutritive  value  of  which  is  rarely  proportionate  to  their  bulk. 


134  MYASTHENIA   GASTRICA. 

Poached  or  lightly  boiled  eggs,  ham,  bacon,  well-cooked  fish, 
and  chicken  which  have  been  passed  through  a  sieve,  sheep's 
brains,  calf's  head,  tripe,  and  sweetbreads  may  be  given  with 
impunity,  and  in  young  persons  raw  meat  pulp  mixed  with  its 
own  juice  is  easily  digested.  Bread  and  other  farinaceous 
substances  are  apt  to  create  flatulence,  and  should  be  omitted 
in  favour  of  toast,  plain  biscuits,  and  the  patent  digested 
preparations  of  Benger,  Savory  &  Moore,  Allen  &  Hanbury, 
or  Nestle.  Uncooked  vegetables  and  fruits  are  always 
injurious,  and  at  most  a  little  potato,  asparagus,  seakale,  or 
cauliflower  should  be  allowed  once  a  day.  If  constipation  is 
present  a  baked  apple  may  be  given  with  the  first  meal. 
Cocoa  made  from  the  nibs  or  husks  is  less  apt  to  disturb  the 
gastric  secretion  than  either  tea  or  coffee  and  in  many  cases  a 
tablespoonful  of  brandy  or  whisky  taken  with  the  food  helps 
to  stimulate  the  appetite  and  to  reheve  the  tendency  to  flatu- 
lence. Persons  who  are  predisposed  by  heredity  to  myasthenia 
or  who  have  previously  suffered  from  neurasthenia,  gastro- 
ptosis,  or  other  condition  that  favours  its  development  should 
wear  a  firm  binder  or  belt  when  they  leave  their  bed,  and  if 
necessary  should  undergo  a  course  of  massage  and  electricity. 
A  dry  bracing  climate  is  more  suitable  than  a  warm  and 
enervating  locality,  and  the  so-called  "water  cures"  invariably 
do  more  harm  than  good. 

General  Measures.  —  Massage. — Many  sufferers  from 
myasthenia  are  in  the  habit  of  relieving  the  discomfort  they 
experience  after  meals  by  rubbing  the  upper  part  of  the 
abdomen,  and  there  is  no  doubt  that  much  benefit  often  results 
from  the  intelligent  and  systematic  employment  of  massage. 
Unfortunately,  every  individual  who  practises  massage  pro- 
claims that  his  method  of  rubbing  the  abdomen  is  the  true 
panacea  for  all  disorders  of  the  stomach  and  intestines,  but 
being  quite  ignorant  of  the  pathology  of  the  inflammatory 
and  ulcerative  diseases  of  the  digestive  organs  as  well  as  the 
strictly  limited  value  of  the  massage  even  in  gastric  myasthenia, 


TREATMENT.  135 

he  often  manages  to  induce  more  injury  than  benefit.  The 
objects  of  massage  are  (i)  to  promote  evacuation  of  the  contents 
of  the  stomach  and  to  increase  its  peristaltic  activity;  (2)  to 
relieve  the  associated  condition  of  intestinal  myasthenia;  (3) 
to  strengthen  the  abdominal  wall. 

(a)  Gastric  peristalsis  may  be  excited  by  gentle  stimulation 
of  the  cutaneous  nerves  of  the  abdomen,  in  the  following 
manner:  The  tip  of  the  right  thumb  of  the  operator  is  placed 
upon  the  abdominal  wall  over  the  centre  of  the  stomach  and 
by  rapid  rotatory  movements  of  the  wrist,  the  tips  of  the 
fingers  are  allowed  to  describe  a  series  of  circles  upon  the 
skin.  No  pressure  is  exercised,  a  fight  brushing  movement 
being  all  that  is  required.  At  intervals  of  a  minute  the  thumb 
is  moved  to  an  adjoining  spot  over  the  region  of  the  stomach 
and  the  process  is  repeated.  This  treatment  is  practised 
night  and  morning  for  ten  minutes,  at  a  time  when  the 
stomach  is  empty,  and  is  particularly  useful  when  myasthenia 
is  accompanied  by  stagnation  of  food.  Patients  soon  learn 
to  perform  it  for  themselves.  Another  method  of  exciting 
gastric  peristalsis  is  to  depress  the  finger  tips  of  both  hands 
deeply  into  the  abdomen  along  the  left  costal  margin,  and  by 
a  series  of  rapid  oscillations  of  the  hands  to  press  the  contents 
of  the  stomach  in  the  direction  of  the  pylorus. 

Zabludowski,  Cseri,  and  others  claim  that  the  gastric 
contents  may  be  squeezed  through  the  pylorus  by  the  adoption 
of  certain  mechanical  movements,  the  method  of  the  last- 
named  being  briefly  as  follows :  the  ulnar  border  of  the  operator's 
left  hand  is  firmly  pressed  into  the  abdomen  along  the  lower 
border  of  the  stomach,  so  that  the  pyloric  end  of  the  organ 
lies  in  the  palm  of  the  hand.  The  fingers  and  thumb  of  the 
right  hand  are  then  pressed  deeply  into  the  fundus  of  the 
stomach,  and  by  a  series  of  pushing  movements  the  contents 
are  forced  toward  the  pylorus. 

(b)  If  the  motions  are  hard  and  constipation  troublesome, 
massage  of  the  lower  bowel  should  be  undertaken  first,  but 


136  MYASTHENIA  GASTEICA. 

if  the  Stools  are  fluid  the  rubbing  may  be  begun  over  the 
cascum.  In  the  former  case  the  right  hand  is  laid  flat  over 
the  upper  part  of  the  decending  colon,  with  the  fingers  of  the 
left  hand  superimposed  upon  it,  the  two  hands  being  slowly- 
moved  downward  and  inward  and  being  made  to  dip  deeply 
into  the  pelvis.  The  right  hand  is  then  placed  flat  upon  the 
caecum,  with  the  ulnar  border  pressing  more  deeply  than  the 
radial,  the  little  finger  and  the  thumb  are  then  slightly  approxi- 
mated, and  with  the  fingers  in  this  position  the  whole  hand 
is  moved  along  the  course  of  the  colon;  the  procedure  being 
repeated  three  or  four  times  each  minute. 

To  increase  the  tone  of  the  abdominal  muscles  massage 
is  applied  to  the  abdominal  wall,  and  the  patient  performs 
regular  daily  exercises  with  active  and  resisted  movements. 

Electricity. — Before  the  introduction  of  the  triphase  alter- 
nating current,  it  was  the  custom  to  employ  the  continuous 
current  to  the  inner  surface  of  the  stomach  by  means  of  an 
intragastric  electrode.  This  method,  which  is  very  distasteful 
to  the  patient,  has  been  practically  superseded  by  the  use 
of  the  polyphase  alternating  current  introduced  by  Reed 
and  Herschell.  When  applied  percutaneously  the  triphase 
current  produces  contractions  of  the  stomach  and  intestines, 
strengthens  their  peristaltic  movements,  and  promotes  the 
evacuation  of  chyme  into  the  duodenum.  The  electrodes 
should  each  possess  the  same  area  and  must  be  well  wetted 
before  being  applied  to  the  skin.  The  patient  lies  upon  a 
couch  with  one  electrode  at  the  side  of  the  dorsal  spine, 
while  the  other  is  placed  upon  the  epigastrium.  The  current 
is  applied  for  ten  to  fifteen  minutes  each  day  for  a  fortnight 
and  then  on  alternate  days  for  another  month.  Many  of  the 
most  obstinate  cases  of  myasthenia  lose  their  symptoms  after 
a  course  of  this  character.  (For  full  particulars  see  Herschell's 
"Manual  of  Intragastric  Technique,"  p.  127.) 

Lavage. — This  is  only  employed  in  cases  of  myasthenia 
accompanied  by  retention  of  food  and   gastrectasis.     It   is 


TREATMENT.  I37 

most  conveniently  performed  in  the  early  morning  before 
breakfast,  unless  the  symptoms  of  dyspepsia  are  present 
during  the  night  and  interfere  with  sleep.  As  a  rule,  warm 
boiled  water  containing  bicarbonate  of  sodium  (one  grain  to 
the  ounce)  is  all  that  is  required,  but  if  gastric  fermentation 
is  active,  some  antiseptic  solution  may  be  used,  such  as 
sahcyhc  acid  (i:i,ooo);  sodium  sahcylate  (i  per  cent.);  per- 
manganate of  potassium  (i:  i,ooo);  boracic  acid  (i  per  cent.), 
or  borax  (5  per  cent.).  Some  authorities  recommend  that 
after  the  organ  has  been  thoroughly  cleansed  with  boiled 
water,  a  pint  of  the  borosalicylic  solution  (boracic  acid  60 
grains,  salicylic  acid  20  grains  to  the  pint  of  water)  should  be 
poured  into  the  viscus  and  allowed  to  remain  in  contact  with 
its  mucous  membrane  for  about  five  minutes  before  being 
withdrawn.  A  teaspoonful  of  glycerin  administered  after 
the  lavage  completes  the  process  of  antisepsis  and  also  acts 
as  a  useful  aperient. 

Turck,  of  Chicago,  has  invented  a  needle-douche,  by 
means  of  which  the  interior  of  the  stomach  is  subjected  to  a 
series  of  fine  streams  of  fluid  ejected  under  considerable 
pressure.  By  the  alternate  use  of  hot  and  cold  water  any 
adherent  mucus  is  removed  and  a  tonic  effect  is  produced  upon 
the  muscular  and  secretory  structures  of  the  organ.  Personally, 
I  have  had  no  experience  of  this  needle-bath  nor  of  the  gyromele 
or  internal  masseur  invented  by  Turck,  and  much  doubt 
whether  these  appliances  can  exert  any  lasting  beneficial 
influence  upon  the  functions  of  the  organ. 

The  subjects  of  myasthenia  almost  invariably  suffer  from 
depressed  circulation  and  experience  an  aggravation  of  their 
symptoms  if  they  are  exposed  to  cold.  It  is  therefore  essential 
that  they  should  be  warmly  dressed  at  all  periods  of  the  year, 
and  during  the  cold  months  should  wear  woollen  underclothes. 
A  belt  of  flannel  or  chamois-leather  also  affords  considerable 
protection  against  sudden  changes  of  temperature,  and  if 
the  stomach  is  dilated  a  firm  belt  appHed  so  as  to  elevate  the 


138  MYASTHENIA   GASTRICA. 

lower  border  of  the  viscus,  as  in  gastroptosis,  will  often  relieve 
the  sensations  of  weight  and  discomfort  at  the  epigastrium. 

Attempts  have  been  made  to  reduce  the  size  of  the  stomach 
by  infolding  the  anterior  wall  of  the  organ  in  the  line  of  its 
long  axis,  and  uniting  the  peritoneal  edges  of  the  infolded 
portion  (Bircher).  I  have  never  yet  met  with  a  case,  how- 
ever, in  which  either  this  operation  or  that  of  gastro-enter- 
ostomy  had  cured  the  manifestations  of  primary  myasthenia. 

When  change  of  air  is  considered  advisable  a  dry,  bracing 
place  should  be  selected  in  preference  to  a  low-lying  or  ener- 
vating locality.  For  this  reason  Scotland,  Yorkshire,  Malvern, 
and  the  east  and  southeast  coasts  usually  agree,  while  the 
south  and  southwest  of  England  almost  invariably  increase 
the  symptoms  of  the  complaint.  If  the  water  is  impregnated 
by  chalk,  Malvern  water  or  salutaris  or  some  other  pure  water 
should  alone  be  drunk.  A  visit  to  Switzerland  in  the  summer 
is  often  attended  by  good  results,  but  as  a  rule  high  altitudes 
should  be  avoided  during  the  winter  months.  When  the 
myasthenia  is  accompanied  by  neurasthenia  or  gastroptosis 
Egypt  or  Algiers  may  be  selected  as  a  winter  resort  with  great 
advantage. 

A  course  of  mineral  waters  is  chiefly  indicated  when 
constipation  and  ansemia  are  prominent  features  of  the  case, 
but  should  be  prescribed  with  caution  when  the  disorder  is 
accompanied  by  gastric  dilatation.  In  the  former  case, 
Kissingen  and  Brides-les-Bains  in  Savoy  are  indicated,  or  if  a 
more  bracing  climate  is  considered  advisable  Tarasp  in  the 
Lower  Engadine  may  be  tried;  while  in  the  latter,  the  iron 
springs  of  St.  Moritz  often  afford  good  results.  Carlsbad 
should  be  avoided  and  Marienbad  is  useless.  A  moderate 
course  of  the  waters  of  Harrogate  or  Llandrindod  is  some- 
times beneficial. 

Diet. — A  proper  dietary  is  a  matter  of  the  greatest  con- 
sequence, and  the  quantity  of  food  as  well  as  the  frequency 
with  which  it  is  administered  must  be  carefully  adjusted  to 


TREATMENT.  I39 

meet  the  special  requirements  of  each  case.  Owing  to  the 
fact  that  liquids  are  apt  to  stagnate  in  the  myasthenic  stomach, 
many  authorities  recommend  an  entirely  dry  diet,  and  only 
permit  a  small  amount  of  fluid  to  be  taken  before  or  after  meals. 
As  a  matter  of  fact,  water  is  one  of  the  most  important  exciters 
of  gastric  secretion,  and  when  given  in  moderate  quantities 
along  with  the  food  also  stimulates  the  contraction  of  the 
gastric  walls.  Unless  hyperacidity  exists,  milk  almost  invari- 
ably disagrees  and  should  never  be  given  in  bulk.  Both  tea 
and  coffee  should  be  prohibited,  and  cocoa  prepared  from  the 
nibs  or  husks  alone  be  allowed.  In  most  instances  a  little 
stimulant  taken  with  the  food  diminishes  the  sense  of  oppres- 
sion and  aids  the  eructation  of  gas,  and  for  this  purpose  a 
tablespoonful  of  good  brandy  or  whisky  mixed  with  4  oz. 
of  hot  water  may  be  allowed  twice  a  day  at  mealtime. 
On  the  other  hand,  malt  liquors  always  disagree  and  wines 
can  rarely  be  tolerated  for  more  than  a  few  days  owing  to  their 
tendency  to  ferment.  In  prescribing  a  dietary  it  should  be 
remembered  that  the  processes  of  digestion  are  delayed  and 
that  stagnation  of  food  in  the  stomach  favours  the  fermentation 
of  its  farinaceous  constituents.  The  frequency  with  which 
food  should  be  given  must  vary  according  to  the  special 
features  of  each  case :  during  the  early  stages  of  the  complaint, 
when  food  stagnation  alone  exists,  a  meal  may  be  allowed 
every  four  hours;  but  when  retention  is  present,  five  hours 
should  be  permitted  to  intervene  between  each  meal. 

An  excess  of  sweets  must  always  be  prohibited,  and  when 
the  stomach  is  dilated  these  substances  should  be  entirely 
eliminated  from  the  dietary.  On  the  other  hand,  well-cooked 
rice  or  corn-flour  or  one  of  the  patent  digested  cereal  foods 
may  be  allowed,  while  toast  or  the  Brusson-Jeune  rolls  are  to  be 
preferred  to  wheaten  bread  or  biscuit.  Green  vegetables  and 
fruits  should  be  entirely  avoided  in  severe  cases,  but  in  mild 
examples  of  the  complaint  a  little  well-cooked  asparagus, 
celery,  or  spinach,  as  well  as  potato  may  be  allowed. 


I40  MYASTHENIA   GASTRICA. 

Meat-fat,  fat  bacon,  ham,  and  salad  oil  are  all  injurious  to 
the  myasthenic  stomach,  owing  to  the  fact  that  they  hinder 
the  secretion  of  gastric  juice  and  delay  the  expulsion  of  the 
gastric  contents  into  the  duodenum.  It  is  advisable,  however, 
to  administer  at  least  half  an  ounce  of  fresh  butter  each  day, 
and,  if  it  can  be  borne,  to  permit  the  use  of  cream.  Lightly 
boiled  or  poached  eggs  form  an  agreeable  addition  to  the 
dietary,  and  can  usually  be  digested  without  difficulty.  The 
white  kinds  of  fish,  such  as  whiting,  sole,  cod,  turbot,  plaice, 
haddock,  and  hake,  are  to  be  preferred  to  the  heavier  and  oily 
varieties,  like  mackerel,  salmon,  and  herring,  and  should  be 
boiled  rather  than  fried,  while  all  forms  of  dried  and  smoked 
fish  should  be  prohibited.  Sweetbreads,  tripe,  sheep's  head 
and  brains,  calf's  head,  calf's  feet,  chicken,  pheasant,  partridge, 
and  tongue  are  easily  digested,  but  venison,  hare,  duck,  goose, 
pigeon,  sausages,  pork,  veal,  curries  and  meats  twice  cooked 
are  rarely  found  to  agree.  Meat  essences,  powders  and 
jellies  may  be  given  with  impunity,  but  soups  and  broths  almost 
invariably  increase  the  sense  of  discomfort  and  distention. 
Raw  meat  pulp  often  agrees  when  all  other  forms  give  rise 
to  discomfort,  and  in  certain  cases  the  so-called  "Salisbury 
treatment"  may  be  advantageously  pursued.  Milk  curdled 
by  means  of  lactobacilline  is  extremely  useful  in  the  second 
stage.  A  three  months'  trial  of  this  remedy  often  completely 
removes  the  symptoms.  It  is  chiefly  indicated  when  there  is  a 
deficiency  of  hydrochloric  acid,  and  is  apt  to  disagree  when 
the  myasthenia  is  associated  with  hyperacidity.  Personally, 
I  have  never  observed  any  good  results  attend  the  use  of  the 
various  tablets  of  the  lactic  acid  bacillus. 

Medicinal. — The  objects  of  medicinal  treatment  are  (i) 
to  prevent  fermentation  of  the  contents  of  the  stomach;  (2) 
to  stimulate  the  muscular  structure  of  the  stomach;  (3)  to 
augment  the  digestive  powers  of  the  gastric  secretion;  (4)  to 
promote  the  evacuation  of  the  bowels. 

(i)  Antiseptic  treatment  should  be  adopted  in  every  instance 


TREATMENT.  I4I 

at  the  outset,  and  stimulating  remedies  deferred  until  the 
tongue  is  clean  and  the  symptoms  of  indigestion  have  to  some 
extent  been  relieved.  The  routine  treatment  of  myasthenia 
by  strychnine,  acids,  and  quinine  usually  does  far  more  harm 
than  good,  since  chronic  gastritis  is  not  infrequently  present 
and  is  exaggerated  by  the  exhibition  of  tonics.  Personally, 
I  prefer  a  mixture  of  carbonate  of  bismuth,  bicarbonate  of 
sodium,  glycerine  of  carbolic  acid  and  peppermint  water  twice 
a  day  between  the  meals.  When  the  tongue  is  foul  half  a 
drachm  of  the  compound  tincture  of  rhubarb  or  2  drachms  of 
the  fresh  infusion  may  be  added  with  advantage,  or  a  drachm 
of  glycerin  if  the  stomach  is  dilated.  Others  prefer  resorcine 
(grs.  10);  bismuth  sahcylate  (grs.  20);  salol  (grs.  10);  beta- 
naphthol  (grs.  3) ;  acid  salicylic  (grs.  10) ;  creasote  or  guaiacol 
(m.  3);  sodium  benzoate  (grs.  5);  iodoform  and  charcoal; 
sodium  hyposulphite  (grs.  20);  sodium  sulphocarbolate 
(grs.  15);  or  the  pil.  acid,  carbolic. 

Excessive  flatulence  may  be  combated  by  peppermint, 
chloroform,  ether,  and  cajuput  mixture,  or  by  the  essence  of 
Ricql^s. 

(2)  The  drugs  which  find  most  favour  as  stimulants  of  the 
musculature  of  the  stomach  are  strychnine,  hydrastin,  quinine, 
ergot,  ipecacuanha,  and  formate  of  sodium.  The  first-named 
is  the  most  rehable  and  may  be  conveniently  given  in  com- 
bination with  quinine  and  phosphoric  acid,  while  in  some 
instances  the  tincture  of  nux  vomica  with  a  bitter  infusion 
is  equally  serviceable.  Hydrastin  and  ergot  are  very  variable 
in  their  action,  and  although  occasionally  they  appear  to  exert 
a  stimulating  influence  upon  the  musculature  of  the  gastro- 
intestinal tract,  they  are  very  apt  to  destroy  the  appetite  and  to 
produce  nausea.  Many  practitioners  favour  the  employment 
of  powdered  ipecacuanha  in  doses  of  1/2  grain  three  or 
four  times  a  day  after  meals,  but  several  weeks  usually  elapse 
before  the  case  exhibits  any  decided  improvement.  Latterly 
formate  of  sodium  has  been  strongly  recommended  by  French 


142  MYASTHENIA   GASTRICA. 

writers  as  a  muscular  tonic,  and  a  distinct  improvement 
sometimes  follows  its  use  in  cases  of  myasthenia  gastrica.  It 
is  most  conveniently  given  in  the  form  of  the  compound  syrup 
or  of  the  tabloids  of  the  polyformiates  (Roberts  &  Co.), 

When  the  myasthenia  appears  to  arise  from  anaemia,  a 
cautious  trial  may  be  made  of  one  of  the  salts  of  iron.  As  a 
rule,  the  ammonio-citrate  agrees  best,  and  may  be  combined 
with  the  solution  of  bismuth  and  bicarbonate  of  sodium. 
The  initial  dose  should  not  exceed  3  grains,  but  the  amount 
may  be  rapidly  increased  if  the  tongue  remains  clean  and  no 
ill  effects  ensue  from  the  use  of  the  drug.  In  other  instances 
the  tartrate  or  ammonio-citrate  of  iron  and  quinine  may  be 
employed,  or  if  a  milder  preparation  is  indicated,  the  dialysed 
solution  or  reduced  iron  may  be  employed.  The  more  astrin- 
gent salts,  such  as  the  sulphate  and  perchloride,  rarely  if  ever 
agree.  If  symptoms  of  neurasthenia  are  present,  valerianate 
of  zinc  combined  with  dioxide  of  manganese  or  the  syrup  of 
glycero-  phosphates  (Robin)  are  valuable  remedies.  Zam- 
belleti's  hypodermic  injections  are  often  most  useful. 

(3)  The  adjuvants  of  the  gastric  secretion  are  pepsin, 
pancreatin,  papain,  diastase,  and  hydrochloric  acid.  Theo- 
retically, pepsin  ought  to  relieve  the  symptoms  of  indigestion 
whenever  the  gastric  secretion  is  deficient  in  digestive  power, 
and  the  market  is  crowded  with  artificial  digestives  of  this 
nature.  As  a  matter  of  fact,  however,  every  stomach,  with 
the  exception  perhaps  of  those  affected  by  atrophy  or  a  con- 
genital absence  of  secretion  (achylia)  is  capable  of  producing 
sufficient  ferment  to  deal  with  every  emergency,  as  long  as  the 
production  of  hydrochloric  acid  is  sustained,  and  hence  the 
success  of  pepsin  in  practice  is  not  commensurate  with  its 
reputation  in  the  laboratory.  Of  the  numerous  preparations, 
the  pure  powder,  the  glycerin  extract,  and  Liebreich's  essence 
are  the  most  reliable,  but  even  with  these  it  is  probable 
that  the  benefit  that  ensues  from  their  use  is  due  more  to  the 
hydrochloric  acid  with  which  they  are  usually  combined  than 


TREATMENT.  1 43 

to  the  ferment  itself.  The  wines  of  pepsin  have  no  thera- 
peutic value  whatever;  indeed,  according  to  the  experiments 
of  Hugouenenq  the  addition  of  wine  to  pepsin  greatly  inter- 
feres with  its  action.  Papain  has  an  advantage  over  pepsin 
in  that  it  is  able  to  convert  proteid  into  peptone  in  an  alkaline 
solution.  Sittmann,  Hirsch,  and  others  have  recorded  excellent 
results  from  its  use  in  cases  of  gastrectasis  accompanied  by  a 
deficient  digestive  power  of  the  gastric  secretion,  but  further 
experience  has  not  corroborated  their  statements,  and  its  use 
is  now  chiefly  confined  to  cases  of  atrophic  gastritis  and 
nervous  achylia. 

Pancreatin  possesses  a  similar  but  more  active  influence 
upon  proteids  than  papain,  but  is  of  little  value  in  gastric 
myasthenia  unless  the  complaint  is  secondary  to  destructive 
gastritis. 

Diastase  is  administered  with  the  view  of  aiding  the  con- 
version of  starch  into  sugar  in  the  stomach.  In  young  children 
maltine  given  after  meals  is  sometimes  of  value,  but  in  adults 
recourse  is  usually  had  to  takadiastase  or  to  diastase  setterie. 
Very  little  is  known  concerning  its  real  value  in  myasthenia, 
but  occasionally  patients  assert  that  the  distention  and  dis- 
comfort after  meals  are  lessened  by  its  employment.  Finally, 
it  may  be  mentioned  that  compressed  tabloids  of  pentenzyme, 
which  consist  of  a  mixture  of  all  the  digestive  glands,  are 
occasionally  found  of  use,  four  to  six  being  administered  after 
each  meal. 

As  compared  with  the  ferments,  dilute  hydrochloric  acid 
often  proves  of  extreme  value  in  cases  of  myasthenia  where 
the  secretion  of  the  acid  is  much  reduced.  As  a  rule,  15 
minims  of  the  dilute  solution  should  be  given  immediately  after 
meals,  but  in  some  instances  a  tumblerful  of  a  0.05  per  cent, 
solution  taken  with  the  food  proves  more  efficacious.  When 
the  myasthenia  is  accompanied  by  inflammation  of  the  gastric 
mucosa  the  acid  should  be  given  with  caution,  as  it  is  very 
apt  to  excite  a  subacute  form  of  gastritis,  and  in  every  instance 


144  MYASTHENIA   GASTRICA. 

its  administration  should  be  interrupted  every  ten  days  for 
three  or  four  days.  The  addition  of  a  teaspoonful  of  glycerin 
to  the  acid  fluid  often  appears  to  increase  its  efficacy. 

(4)  No  medicinal  remedy  exerts  any  permanent  influence 
upon  the  digestive  disorder  unless  care  is  taken  to  procure 
a  daily  evacuation  of  the  bowels.  In  many  cases  this  is 
ultimately  attained  by  means  of  the  massage,  electricity 
and  exercises  already  mentioned,  but  few  cases  of  myasthenia 
obtain  any  permanent  benefit  without  recourse  being  had  to 
aperients.  In  this  connection  it  is  important  to  observe  that 
salines  and  drastic  purgatives  usually  do  more  harm  than 
good  unless  the  disorder  is  complicated  by  gastritis,  and 
conversely  that  the  mildest  aperient  is  usually  the  most 
efficacious.  When  the  constipation  is  of  a  mild  type  or  only  of 
occasional  occurrence,  a  large  enema  twice  a  week  or  an 
injection  of  glycerin  may  be  all  that  is  necessary,  or  the  patient 
may  be  directed  to  take  a  tumblerful  of  hot  water  with  three 
or  four  prunes  in  the  early  morning.  In  other  instances  a 
combination  of  the  liquid  extract  of  cascara  with  maltine 
taken  each  evening  before  the  last  meal  procures  an  easy 
evacuation  on  the  following  morning,  or  a  few  grains  of 
cascara  or  a  pinch  of  Turkish  rhubarb,  or  a  cup  of  Garfield's 
tea  at  night  will  be  found  sufficient.  In  more  severe  cases 
euonymin  and  rhubarb,  aloes  and  iron,  or  some  other  mild 
pill  is  required,  the  dose  being  gradually  reduced  as  the  case 
improves. 


CHAPTER  IV. 

DYSPEPSIA  DUE  TO  INFLAMMATIONS  OF  THE 
STOMACH. 

(i)  Acute  Gastritis.     (2)  Chronic  Gastritis.     (3)  Atrophy 
of  the  Stomach. 

(i)  ACUTE  GASTRITIS. 

Etiology. — Acute  inflammation  of  the  mucous  membrane 
of  the  stomach  is  one  of  the  commonest  diseases  to  which 
the  body  is  Hable,  but  since  in  the  majority  of  the  cases  the 
disorder  is  extremely  shght  and  temporary  in  character,  it  is 
only  the  more  severe  and  persistent  examples  that  come  under 
the  notice  of  the  physician.  In  my  statistics  which  deal 
with  hospital  practice,  14.2  per  cent,  of  persons  complaining 
of  indigestion  were  found  to  be  suffering  from  this  particular 
disorder. 

Age  and  Sex. — The  complaint  is  most  frequent  in  children 
under  ten  years  of  age,  and  is  particularly  rife  among  bottle- 
fed  infants  who  are  exposed  to  the  dangers  of  food  infection 
(Chapter  VIII).  It  is  also  common  among  old  persons  whose 
digestive  organs  have  been  weakened  by  disease  and  whose 
powers  of  mastication  have  been  impaired  or  lost  from  decay 
of  the  teeth.  Throughout  life  males  are  more  liable  to  the 
disease  than  females,  the  ratio  of  the  two  sexes  being  rather 
more  than  3  to  2. 

Although  it  has  become  the  custom  of  recent  years  to 
ignore  hereditary  influences  in  the  causation  of  gastric  com- 
plaints, there  can  be  no  doubt  that  the  clinical  observations 
recorded  by  writers  during  the  eighteenth  and  nineteenth 
centuries  were  quite  correct  and  that  certain  families  possess 
a  marked  predisposition  to  gastric  inflammation.  Unhke 
10  145 


146  ACUTE   GASTRITIS. 

myasthenia,  the  tendency  to  gastritis  displays  itself  at  an 
early  period  of  life,  and  usually  becomes  less  apparent  after 
the  age  of  thirty. 

Persons  who  are  thus  affected  are  commonly  said  to  suffer 
from  "delicate"  or  "weak  digestions,"  since  any  departure 
from  a  strict  diet  or  carefully  considered  mode  of  life  is  at  once 
followed  by  the  symptoms  of  acute  indigestion.  These  cases 
may  be  divided  into  two  classes — the  idiosyncratic  and  the 
nervous.  In  the  former,  the  digestive  organs  appear  to  be 
endowed  with  certain  highly  developed  idiosyncrasies  with 
regard  to  particular  articles  of  food,  the  ingestion  of  which 
gives  rise  to  inflammation  of  the  stomach  and  sometimes 
also  to  enteritis.  Thus,  sweets,  fats,  cream,  eggs,  almonds, 
oatmeal,  mackerel,  shellfish,  liver,  game,  coffee,  acid  drinks, 
alcohol,  and  tobacco  are  very  apt  to  excite  acute  gastric  in- 
flammation in  certain  individuals,  while  in  others  even  small 
doses  of  such  drugs  as  digitalis,  strychnine,  morphine,  saHcylate 
of  sodium,  iodide  of  potassium,  iron,  quinine,  nitroglycerin, 
and  even  bicarbonate  of  sodium  prove  equally  deleterious. 
In  the  second  class  psychical  conditions  are  chiefly  responsible 
for  the  disorder,  and  many  children  immediately  suffer  from 
an  attack  if  they  become  excited,  fatigued,  or  exhibit  an 
emotional  outburst.  The  predisposition  is  more  often  trans- 
mitted by  the  mother  than  the  father. 

x^cute  gastritis  is  particularly  common  during  the  spring 
and  early  summer,  at  which  times  it  not  infrequently  assumes 
an  epidemic  character.  As  the  result  of  an  analysis  of  327 
cases,  Willigk  gave  the  following  relative  proportions  between 
the  number  of  cases  occurring  at  different  seasons:  Spring,  6.2; 
summer,  3.4;  autumn,  2.9;  winter,  2.5.  Epidemics  frequently 
ensue  after  the  breaking  up  of  a  prolonged  drought  or  the  sub- 
sidence of  high  winds,  and  in  this  connection  it  is  interesting 
to  note  that  Todd  observed  outbreaks  of  the  disorder  to 
follow  the  hise  in  Switzerland,  the  mistral  in  Provence,  and 
the   tramontana   in   Italy.     In   England,    Brighton   has   long 


ETIOLOGY.  147 

enjoyed  a  reputation  for  "biliousness,"  and  many  individuals 
invariably  suffer  from  vomiting  and  other  symptoms  of  acute 
gastritis  if  they  remain  in  the  place  for  a  few  hours. 

Acute  gastritis  may  ensue  either  from  direct  irritation  of 
the  stomach  or  develop  as  a  consequence  of  some  systemic 
disorder  or  of  disease  of  another  important  viscus  of  the  body. 
From  an  etiological  stand-point  two  varieties  may  therefore 
be  recognised,  the  primary  and  the  secondary. 

Primary  acute  gastritis  varies  greatly  in  its  intensity  in 
different  cases,  being  comparatively  slight  and  transient  in 
character  when  the  local  irritation  is  unimportant  and  easily 
removed,  but  extremely  severe  and  enduring  in  its  effects  when 
the  ingestion  of  a  corrosive  has  given  rise  to  tissue  destruction. 

In  the  majority  of  cases  the  acute  inflammation  of  the 
stomach  is  induced  by  the  ingestion  of  food,  the  quantity, 
quality  or  temperature  of  which  induces  irritation  of  the 
gastric  mucous  membrane.  It  is  commonly  believed  that  a 
mere  excess  of  food  is  capable  of  exciting  the  disorder,  and 
there  is  no  doubt  that  acute  gastritis  frequently  follows  in- 
dulgence in  an  abnormally  large  meal,  especially  in  young 
subjects.  It  is  extremely  doubtful,  however,  whether  mere 
overloading  a  healthy  stomach  with  substances  which  are 
eminently  digestible  is  capable  of  setting  up  a  catarrhal  process. 
On  the  other  hand,  any  antecedent  or  concomitant  condition 
which  interferes  with  the  secretory  or  motor  powers  of  the 
stomach  will  promote  the  fermentation  of  the  contents  of  the 
organ  when  it  is  the  recipient  of  an  unduly  large  though  other- 
wise digestible  meal.  The  acute  gastritis  which  so  often 
follows  indulgence  in  solid  food  after  a  period  of  starvation  is 
probably  due  to  the  deficiency  of  gastric  juice  which  results 
from  such  abstention  (Bidder  and  Schmidt),  and  the  epidemics 
of  acute  dyspepsia,  which,  according  to  Barras,  used  to  coincide 
with  the  termination  of  Lent,  apparently  originated  from  a 
similar  cause.  In  like  manner,  children  often  suffer  from  a 
mild  attack  of  gastritis  when  they  indulge  in  a  full  meal 


148  ACUTE   GASTRITIS. 

after  a  period  of  unusual  excitement  or  fatigue,  the  nervous 
element  in  these  cases  having  produced  a  temporary  inhibition 
of  both  gastric  peristalsis  and  secretion.  In  other  instances, 
again,  it  is  the  composition  rather  than  the  size  of  the  meal 
that  is  responsible  for  its  injurious  effects.  Thus,  such  sub- 
stances as  starch,  fat,  or  cellulose,  which  undergo  little  or 
no  digestion  in  the  stomach,  are  apt  to  remain  unduly  long  in 
the  viscus  and  to  excite  irritation  of  its  mucous  membrane. 
In  young  children  such  mechanical  irritation  is  a  factor  of 
considerable  importance,  but  after  puberty  the  disease  is 
almost  invariably  brought  about  by  chemical  rather  than 
mechanical  agencies,  and  its  exciting  cause  is  to  be  found  in 
the  action  of  various  products  of  food  decomposition  upon  the 
inner  surface  of  the  organ.  These  chemical  irritants  may 
either  exist  in  the  food  at  the  time  of  its  ingestion  or  they  may 
develop  as  the  result  of  its  fermentation  in  the  stomach.  In 
the  former  case,  the  meat,  broth,  fish,  or  milk  has  undergone 
incipient  putrefaction  outside  the  body,  and  the  organic  poisons 
thus  formed  either  exert  an  immediate  local  action  upon  the 
gastric  mucosa,  or,  as  is  more  probable,  are  absorbed  into 
the  general  circulation,  and  subsequently  eliminated  as  ir- 
ritants by  the  glandular  structures  of  the  gastrointestinal  tract. 
In  this  cormection  it  is  important  to  remember  that  certain 
articles  of  diet  are  more  prone  to  develop  poisonous  properties 
than  others,  and  that  some  individuals  are  unduly  susceptible 
to  their  influence.  Among  fish,  mackerel  is  particularly 
dangerous,  while  gurnet,  eels,  salmon,  sardines,  anchovies, 
crabs,  and  oysters  are  also  occasionally  productive  of  severe 
gastroenteritis.  Smoked  or  partially  cured  fish  may  also  prove 
poisonous.  All  forms  of  animal  food,  as  well  as  broths  and  es- 
sences prepared  from  them,  are  liable  to  undergo  putrefaction 
and  to  develop  organic  poisons  of  the  most  virulent  nature 
without  the  production  of  any  offensive  taste  or  smell,  and 
which  no  ordinary  method  of  cooking  will  render  innocuous. 
Venison,  overhung  meat  and  game,  cheese,  foie  gras,  tripe. 


ETIOLOGY.  149 

mushrooms,  and  truffles  are  particularly  dangerous  to  certain 
people. 

Sometimes  acute  inflammation  of  the  stomach  is  excited  by 
the  ingestion  of  food  which  was  unduly  hot  or  too  cold.  Boiling 
water  provokes  a  very  severe  form  of  gastritis  accompanied  by 
superficial  ulceration,  and  the  dyspepsia  from  which  cooks  so 
frequently  suffer  has  been  attributed  to  their  habit  of  tasting 
hot  foods.  This,  however,  is  extremely  doubtful.  Indulgence 
in  cold  water  and  iced  drinks  after  severe  physical  exercise 
occasionally  excites  an  inflammatory  condition  of  the  stomach, 
but  the  gastroenteritis  that  sometimes  follows  the  ingestion  of 
ices  is  more  often  due  to  the  poisonous  nature  of  their  constit- 
uents than  to  their  temperature. 

Extremes  of  heat  and  cold  occasionally  give  rise  to  gastritis 
through  their  influence  upon  the  skin.  Cold  winds  are  es- 
pecially dangerous  in  this  respect,  and  many  persons  habitually 
suffer  from  inflammation  of  the  stomach  after  undue  exposure. 
Conversely,  firemen,  stokers,  glass-blowers,  and  workers  in 
furnaces  are  liable  to  a  severe  form  of  gastritis,  accompanied 
sometimes  by  violent  spasm  of  the  colon  and  dangerous 
collapse,  if  they  suddenly  emerge  into  a  cold  atmosphere  or 
drink  cold  water.  The  violent  inflammation  of  the  stomach 
which  ensues  from  swallowing  strong  acids  or  alkalies  is  too 
well-known  to  require  more  than  a  passing  notice,  but  it  should 
always  be  borne  in  mind  that  many  drugs  administered  in 
medicinal  doses  may  be  the  unsuspected  cause  of  troublesome 
gastric  inflammation.  Thus,  mustard,  antimony  and  ipeca- 
cuanha owe  their  emetic  effect  to  direct  irritation  of  the  stomach 
which  may  proceed  to  inflammation,  while  apomorphine  when 
injected  beneath  the  skin  is  partially  excreted  by  the  gastric 
mucosa  with  the  production  of  catarrhal  changes  in  the  peptic 
glands.  A  marked  degree  of  intolerance  is  also  displayed  by 
many  persons  toward  minute  doses  of  such  drugs  as  iron, 
phosphorus,  quinine,  nux  vomica,  creasote,  copaiba,  sandal- 
wood oil,  antifebrin,  antipyrin,  salicylates,  iodides,  bromides, 


150  ACUTE   GASTRITIS. 

bitter  infusions,  and  mineral  acids,  while  even  wall  papers 
containing  arsenic  (King  Chambers)  and  lead  lotions  have 
been  known  to  cause  gastritis.  Occasionally  the  disease 
presents  epidemic  features.  In  most  instances  of  this  kind 
acute  gastritis  appears  coincidently  with  outbreaks  of  diseases 
which  exert  a  specific  action  upon  the  digestive  tract,  such  as 
cholera  (Barras,  Fox,  Chomel),  dysentery  (Sydenham),  and 
typhoid  (Broussais),  but  it  also  accompanies  certain  epidemics 
of  influenza.  Chantemesse  has  drawn  attention  to  the  occur- 
rence of  epidemic  gastritis  whenever  the  water  of  the  Seine 
was  distributed  to  Paris,  and  Gaffky  has  reported  three  cases 
which  were  traced  to  the  use  of  milk  obtained  from  a  cow 
that  was  suffering  from  hsemorrhagic  enteritis.  The  latter 
observer  has  also  shown  that  many  cases  of  meat  and  sausage 
poisoning  are  due  to  the  presence  of  pathogenic  micro-organ- 
isms. It  would,  therefore,  appear  that  not  only  are  there  certain 
definite  forms  of  acute  gastritis  which  may  be  termed  infectious 
in  contradistinction  to  toxic,  but  that  the  micro-organism, 
which  in  one  individual  will  produce  a  specific  disorder  like 
cholera,  typhoid,  or  dysentery,  will  in  another  merely  initiate  a 
more  or  less  severe  inflammation  of  the  gastrointestinal  tract. 
In  one  case  which  came  under  the  writer's  notice,  three 
people  became  infected  by  an  intensely  virulent  species  of 
the  B.  coli  commune,  one  of  whom  almost  lost  her  life  from 
acute  ulcerative  colitis,  while  the  other  two  suffered  from 
moderate  gastritis  and  gastroenteritis,  respectively. 

Finally,  it  may  be  observed  that  psychical  impulses  and 
nervous  disturbances  are  often  held  responsible  for  an  attack 
of  gastritis  or  "biliousness",  excitement,  anger,  anxiety,  or 
shock  being  followed  immediately  by  the  symptoms  of  the 
complaint.  It  is  probable  that  emotions  of  this  nature  inhibit 
the  secretion  of  the  stomach  and  also  produce  a  temporary 
paresis  of  its  muscular  structure,  with  the  result  that  the  food 
present  in  the  organ  undergoes  rapid  fermentation  and  thus 
excites  local  irritation  of  the  gastric  mucosa. 


ETIOLOGY,  151 

Secondary  Acute  Gastritis. — This  is  a  common  complication 
of  diseases  both  of  the  stomach  itself  and  of  other  important 
organs  of  the  body.  All  varieties  of  chronic  inflammation  of 
the  stomach  are  apt  to  exhibit  from  time  to  time  an  acute 
phase  of  the  complaint,  while  cases  of  simple  ulcer,  cancer, 
sarcoma,  gastrectasis,  hypersecretion,  myasthenia  and  gas- 
troptosis  almost  invariably  display  the  symptoms  of  acute 
gastritis  at  some  period  of  their  course. 

Diseases  which  cause  obstruction  of  the  portal  circulation 
produce  venous  congestion  of  the  stomach  and  thus  predispose 
to  the  development  of  gastritis;  consequently,  valvular  affec- 
tions of  the  heart,  emphysema,  chronic  phthisis,  interstitial 
pneumonia,  bronchiectasis,  cirrhosis  of  the  hver,  perihepatitis, 
pressure  on  the  portal  vein,  and  enlargements  of  the  spleen  are 
all  liable  to  be  attended  by  inflammatory  disorders  of  the 
stomach.  Acute  inflammation  of  the  kidney  is  invariably 
accompanied  by  an  acute  parenchymatous  gastritis  (Fox, 
Fenwick),  which  is  also  a  pronounced  feature  of  many  specific 
febrile  diseases  at  their  commencement,  especially  scarlatina 
(Fenwick),  measles  (Barthez  and  RilHet),  cholera  (Andral), 
typhoid,  diphtheria,  variola,  erysipelas  (Bamberger,  Frank), 
pneumonia,  puerperal  fever,  (Fox),  tuberculosis  (Fenwick, 
Marfan),  and  influenza.  Pyaemia  is  invariably  accompanied 
by  inflammation  of  the  gastrointestinal  tract,  and  cases  have 
been  recorded  in  which  phlebitis  was  ushered  in  by  symptoms 
of  the  disorder.  There  is  also  good  reason  to  believe  that 
inflammation  of  the  stomach  plays  an  important  part  in  the 
causation  of  the  pernicious  vomiting  of  pregnancy.  Severe 
burns  and  scalds  of  the  skin  are  apt  to  be  followed  by  intense 
inflammation  of  the  alimentary  canal,  especially  of  the  stomach 
and  duodenum,  which  sometimes  proceeds  to  ulceration 
(Erichsen),  and  in  certain  cases  of  acute  general  eczema  the 
cutaneous  affection  alternates  with  attacks  of  severe  gastritis 
(Samuel  Fenwick). 

Primary  mycoses  of  the  stomach  are  always   associated 


152  ACUTE   GASTRITIS. 

with  acute  inflammation  of  the  organ,  and  cases  have  been 
recorded  in  which  favus  (Kundrat),  thrush  (Rosenheim), 
anthrax  (Birch-Hirschfeld,  Martin),  and  diphtheria  (Smirnow, 
Fenwick)  attacked  a  considerable  area  of  the  inner  surface  of 
the  viscus.  Finally,  gastritis  of  an  acute  as  well  as  a  chronic 
type  ensues  from  the  irritation  of  foreign  bodies,  larvse, 
ascarides,  taeniae,  and  other  living  creatures. 

Pathology. — Our  knowledge  of  the  pathological  changes 
in  the  stomach  which  ensue  from  acute  inflammation  is 
extremely  limited,  partly  because  uncomplicated  cases  of  the 
disease  rarely  terminate  fatally  and  partly  by  reason  of  the 
autodigestion  of  the  tissues  which  occurs  immediately  after 
death  and  has  the  effect  of  destroying  the  greater  portion  of 
the  mucous  membrane.  The  earliest  and  most  reliable  obser- 
vations upon  the  subject  were  made  by  Beaumont,  who  was 
able  to  observe  the  state  of  the  stomach  through  a  fistulous 
opening,  and  although  many  modern  pathologists  (Fleiner, 
Fleischer)  appear  to  regard  his  statements  as  untenable  in  the 
light  of  modem  knowledge,  there  cannot  be  the  slightest  doubt 
that  Beaumont's  observations  were  correct.  Thus,  we  are 
told  that  when  the  patient  had  overeaten  himself,  the  inner 
surface  of  the  stomach  appeared  to  be  swollen  and  hyperaemic, 
and  was  covered  with  a  thick  layer  of  tenacious  mucus.  The 
secretion  was  also  greatly  diminished,  and  was  mostly  neutral 
or  alkaline  in  reaction,  while  food  introduced  into  the  organ 
underwent  little  or  no  solution  and  remained  stagnant  from 
four  to  six  hours.  A  still  more  vivid  picture  of  inflammation 
is  afforded  by  the  appearance  of  the  stomach  after  the  patient 
had  taken  an  excess  of  ardent  spirits  for  several  days,  when 
the  mucous  membrane  presented  eruptions  of  deep  red 
pimples  and  pustules,  interspersed  with  crimson  patches  half 
an  inch  to  an  inch  and  a  half  in  circumference,  aphthous  crusts, 
and  abrasions,  with  grumous  blood  exuding  from  several 
separate  points.  It  was  also  noted  that  the  gastric  fluids  were 
mixed   with    thick   ropy   mucus   and   muco-purulent   matter 


CLINICAL   VARIETIES   AND    THEIR    SYMPTOMS.  1 53 

slightly  tinged  with  blood,  possessed  a  fetid  and  disagreeable 
odour,  and  resembled  the  discharge  from  the  bowels  in  some 
cases  of  chronic  dysentery. 

Most  of  the  microscopical  observations  have  been  made 
upon  animals  in  which  acute  gastritis  had  been  induced  by 
various  methods.  In  such  preparations,  as  well  as  in  isolated 
cases  occurring  in  the  human  subject,  the  earliest  sign  of 
inflammation  is  a  granular,  cloudy  swelling  of  the  superficial 
epithelium  which  proceeds  at  a  later  stage  to  mucoid  degener- 
ation of  the  cylindrical  cells  and  to  their  detachment  from  the 
basement  membrane.  In  the  pyloric  region  these  appearances 
involve  the  glands  throughout  their  entire  length,  but  in  the 
cardiac  two-thirds  of  the  organ  the  parietal  and  peptic  cells 
are  indistinguishable  from  one  another,  and  become  cloudy, 
granular,  contracted,  or  filled  with  globules  of  fat.  The 
capillaries  in  the  superficial  layers  of  the  mucosa  and  between 
the  glands  are  much  dilated  and  choked  with  corpuscles;  small 
haemorrhages  are  present  here  and  there,  and  an  accumulation 
of  small,  round  cells  may  be  observed  in  the  connective  tissue, 
mixed  with  leucocytes  and  red  corpuscles.  Karyokinetic 
figures  are  sometimes  observed  in  the  emigrated  leucocytes 
and  superficial  epthelium,  which,  according  to  Sachs,  are 
characteristic  of  acute  gastritis.  In  severe  examples  of  the 
disease  capillary  congestion  and  exudation  is  also  present  in 
the  deeper  layers  of  the  mucosa  and  in  the  submucosa,  accom- 
panied by  hyperaemia  and  swelling  of  the  solitary  glands. 

Clinical  Varieties  and  Their  Symptoms. — Acute  inflam- 
mation of  the  stomach  may  arise  from  so  many  causes  and 
present  such  various  grades  of  severity  that  an  accurate 
classification  of  its  protean  features  is  almost  a  matter  of 
impossibility.  It  is  true  that  in  recent  text-books  upon 
diseases  of  the  stomach  much  ingenuity  is  shown  in  the 
minute  analysis  of  symptoms  and  the  differentiation  of  many 
varieties  and  sub  varieties  of  the  complaint;  but  a  careful 
consideration  proves  that   the  principal  points  of  distinction 


154  SIMPLE  ACUTE   GASTRITIS. 

between  these  so-called  clinical  forms  are  either  etiological 
or  pathological,  while  the  symptoms  themselves  differ  only  in 
their  severity  or  duration.  When  it  is  borne  in  mind  that  no 
constant  relationship  exists  between  the  degree  of  gastric 
inflammation  and  the  severity  of  its  resultant  symptoms,  and 
that  the  same  cause  will  in  one  person  excite  a  dangerous  form 
of  gastritis  while  in  another  its  effects  are  comparatively  mild 
and  evanescent,  it  is  obvious  that  a  clinical  description  must  be 
based  entirely  upon  clinical  considerations,  and  should  be 
made  as  simple  as  possible. 

Acute  gastritis  may  conveniently  be  divided  into  two  great 
classes,  the  simple  and  the  toxic.  In  the  former  the  disease 
tends  to  undergo  spontaneous  resolution  like  other  simple 
inflammations,  and  its  constitutional  symptoms  are  sub- 
ordinate to  those  which  ensue  from  the  inflamed  viscus;  while 
in  the  latter  actual  destruction  of  tissue  often  results,  and 
secondary  phenomena  of  a  diverse  and  dangerous  nature  may 
take  precedence  of,  and  even  mask  the  distinctive  indications 
of  the  gastritis.  The  fact  that  certain  cases  of  simple  gastritis 
are  accompanied  by  a  degree  of  fever  which  renders  their 
diagnosis  a  matter  of  difficulty  must  constitute  an  excuse  for 
the  subdivision  of  that  variety  into  a  non-febrile  and  a  febrile 
class. 

SIMPLE  ACUTE  GASTRITIS. 

(i)  The  Non-febrile  Variety. — This  is  most  frequently 
encountered  in  families  which  are  predisposed  to  the  com- 
plaint, and  is  apt  to  be  excited  by  an  unduly  large  meal  after 
prolonged  abstention  or  severe  physical  exercise,  by  a  strong 
emotion,  or  by  indulgence  in  some  form  of  material  or 
drug  against  which  an  idiosyncrasy  exists  on  the  part  of  the 
patient.  As  a  rule,  it  develops  suddenly  and  without  pre- 
monitory phenomena,  but  in  young  children  an  attack  is 
sometimes  preceded  by  increased  appetite  and  a  wonderful 
buoyancy  of  spirits. 


THE    NON-FEBRILE    VARIETY.  155 

The  first  symptoms  are  usually  a  sense  of  fatigue,  general 
malaise,  and  aching  in  the  back,  limbs,  and  head,  followed 
in  a  short  time  by  epigastric  discomfort  and  distention.  To 
these  a  dull  frontal  headache  is  soon  added,  and  not  infre- 
quently severe  cramp-like  pains  in  the  abdomen,  attended  by 
giddiness,  faintness,  palpitation,  and  a  fear  of  impending  death 
are  also  observed.  When  the  headache  is  exceptionally 
violent,  there  may  be  intolerance  of  light  and  sound,  and 
profuse  sweating,  while  in  children  slight  strabismus,  rest- 
lessness, an  inspiratory  form  of  dyspnoea,  and  hiccough,  with  a 
slow,  weak  pulse,  are  occasionally  early  symptoms.  As  a  rule, 
an  increased  flow  of  saliva  ushers  in  a  feeling  of  intense  nausea 
which  culminates  in  the  rejection  by  the  stomach  of  the  last 
meal.  Less  frequently  the  gastric  contents  pass  into  the 
intestine  where  they  excite  griping  pains  followed  perhaps  by 
several  loose  actions  of  the  bowels.  Although  the  initial 
emesis  gives  considerable  relief,  and  in  some  instances  cuts 
short  the  further  progress  of  the  disorder,  nausea  usually 
recurs  after  an  interval  and  is  attended  by  severe  and  repeated 
attacks  of  retching.  As  soon  as  the  remnants  of  the  last  meal 
have  been  expelled,  the  vomit  consists  entirely  of  a  viscid,  bile- 
stained  mucus,  the  rejection  of  which  is  often  accompanied , 
by  such  severe  straining  that  fibres  of  the  abdominal  muscles  I: 
are  apt  to  become  torn  with  the  production  of  acute  pain  in 
the  epigastrium.  Occasionally  the  structure  of  the  diaphragm  \ 
suffers  a  similar  lesion,  and  a  week  or  more  may  elapse  before/ 
respiration  ceases  to  be  accompanied  by  pain,  while  in  other 
instances  a  severe  stabbing  pain  in  the  perinseum  suggests 
slight  laceration  of  the  levator  ani. 

As  a  result  of  the  violent  retching  the  skin  of  the  face  and 
neck  becomes  suffused  and  punctiform  haemorrhages  may 
appear  on  the  forehead,  cheeks,  and  beneath  the  conjunctivae, 
while  straining  of  the  pharyngeal  muscles  in  the  effort  to  expel 
the  mucus  from  the  stomach  not  infrequently  causes  the  ejecta 
to  become  tinged  with  blood.     In  elderly  persons  congestion 


156  SIMPLE  ACUTE   GASTRITIS. 

of  the  brain  from  the  same  cause  may  give  rise  to  semi-uncon- 
sciousness or  even  to  apoplexy.  An  attack  of  retching  is 
often  excited  by  a  movement  of  the  body,  an  attempt  to 
swallow  food  or  even  by  speaking;  but  in  cases  where  the 
patient  habitually  vomits  with  difficulty,  retching  is  apt  to 
prove  particularly  distressing  and  to  result  in  little  or  no  relief. 
The  subjects  of  gastroptosis  suffer  disproportionately  in  this 
respect,  and  in  certain  cases  of  simple  gastritis  vomiting 
is  impeded  or  entirely  prevented  by  a  spasmodic  contraction 
of  the  oesophagus  or  cardiac  orifice  (Skoda) . 

As  a  rule,  after  manifesting  itself  at  short  intervals  for 
twelve  hours  or  longer,  the  retching  and  vomiting  gradually 
become  less  frequent  and  finally  subside  along  with  the 
salivation  and  nausea. 

The  character  of  the  vomit  varies  at  different  times.  At 
first  it  consists  of  undigested  food,  the  particles  of  which  are 
coated  with  a  tenacious  mucus  and  possess  a  sour  and  dis- 
agreeable smell.  Although  acid  in  reaction,  free  hydrochloric 
acid  is  almost  invariably  absent,  and  the  total  acidity  of  the 
fluid  after  filtration  is  found  to  be  much  reduced.  Occasion- 
ally the  ejecta  are  neutral  or  even  alkaline.  If  the  last  meal 
contained  much  fat  or  farinaceous  material,  products  of 
fermentation  in  the  form  of  lactic  and  butyric  acid,  with  perhaps 
traces  of  fatty  acids,  may  often  be  detected.  The  presence  of 
acetic  acid  usually  indicates  the  administration  of  alcohol. 
Senator  has  drawn  attention  to  the  occasional  existence  of 
sulphuretted  hydrogen  in  the  stomach  and  urine  as  a  result 
of  excessive  decomposition  of  albuminoids,  but  this  abnormal 
product  is  extremely  rare.  At  a  later  stage  the  vomit  consists 
entirely  of  thick,  opalescent  mucus,  mixed  with  yellow  or  green 
bile  and  occasionally  with  traces  of  blood.  As  the  result  of 
excessive  straining,  round  worms  and  other  intestinal  parasites^ 
are  sometimes  forced  through  the  pylorus  and  subsequently., 
vomited.  '  '"' '  "■''""^' 

For  several  days  after  the  subsidence  of  the  complaint,  an 


THE    NON-FEBRILE    VARIETY.  1 57 

analysis  of  the  gastric  contents  will  show  that  the  stomach  only 
recovers  its  digestive  powers  in  a  very  gradual  manner,  since 
the  particles  of  bread  consumed  at  the  test-breakfast  are 
mixed  with  mucus  and  show  signs  of  tardy  digestion,  while 
the  total  acidity  remains  abnormally  low  and  free  hydrochloric 
acid  is  absent. 

During  the  crisis  of  the  attack  the  patient  exhibits  extreme 
listlessness  and  appears  weak  and  ill.  The  face  and  lips  are 
pale,  the  eyes  sunken  and  surrounded  by  black  or  bluish  lines, 
and  the  forehead  is  often  covered  with  a  cold  sweat.  The 
lips  are  dry  and  cracked,  and  an  eruption  of  herpes  sometimes 
appears  upon  the  face  or  ear.  The  tongue  is  moist,  swollen, 
covered  with  a  thick,  creamy  fur  and  indented  along  the 
margins  by  the  teeth,  while  its  posterior  third  is  usually  stained 
by  any  medicine  or  food  which  has  been  taken.  The  breath 
is  offensive,  the  saliva  abundant  and  abnormally  viscid,  and 
complaint  is  made  of  an  acid,  bitter,  or  insipid  taste  in  the 
mouth.  The  circulatory  system  is  depressed,  and  the  pulse 
is  small,  slow,  and  compressible.  The  urine  is  scanty,  high 
coloured,  and  deposits  urates  after  standing;  occasionally  it 
possesses  a  sweet  odour,  like  that  voided  in  diabetes,  when  the 
addition  of  a  few  drops  of  the  solution  of  perchloride  of 
iron  produces  a  blood-red  colouration,  or  a  small  quantity  of 
indican  may  be  detected  in  it.  The  appetite  remains  in  abey- 
ance during  the  whole  course  of  the  disorder  and  the  utmost 
loathing  may  be  expressed  toward  food  of  any  kind,  while 
its  forcible  administration  is  at  once  followed  by  retching  or 
vomiting.  On  the  other  hand,  as  soon  as  the  acute  symptoms 
have  subsided  there  is  often  a  craving  for  acid,  salt,  or  piquant 
foods,  and  lemons  will  be  devoured  with  avidity,  as  though 
the  patient  was  unconsciously  endeavouring  to  supplement  the 
deficient  acidity  of  his  gastric  secretion.  Thirst  is  always 
present  and  may  be  insatiable.  In  children,  and  also  in  those 
who  suffer  from  engorgement  of  the  portal  system,  the  breath 
usually  smells  of  acetone,  and  the  sweet  odour  usually  persists 


158  SIMPLE  ACUTE   GASTRITIS. 

until  the  normal  appetite  returns.  The  lassitude,  depression, 
and  headache  are  sometimes  attributed  to  this  mild  acetonaemia, 
but,  according  to  my  experience,  no  constant  relation  exists 
between  the  intensity  of  the  acetonuria  and  the  severity  of 
the  nervous  symptoms. 

The  bowels  are  usually  confined,  and  the  evacuations  are 
hard,  knotty,  drab-coloured,  and  extremely  ofi'ensive.  Occa- 
sionally, and  especially  in  young  subjects,  they  are  loose  and 
frothy,  or  green  from  the  presence  of  altered  bile. 

In  severe  cases  symptoms  due  to  disturbance  of  the  central 
nervous  system  are  rarely  absent,  and  complaint  is  made  of 
faintnessj  .giddiness,  palpitation,  and  dyspnoea,  while  in  some 
instances  loss  of  memory  or  a  confusion  of  ideas  supervenes. 
These  secondary  phenomena  are  particularly  common  in 
females  and  young  children,  in  whom  a  semi-comatose  con- 
dition or  even  epileptiform  convulsions  occasionally  occur. 
The  degree  of  headache  also  varies  considerably  in  different 
cases,  and  is  sometimes  so  intense  as  to  suggest  inflammation 
of  the  meninges.  In  other  instances  where  vomiting  and 
headache  recur  at  intervals,  the  attacks  may  closely  resemble 
those  of  migraine,  to  which  in  reahty  they  are  closely  allied. 

The  inflammatory  affection  of  the  stomach  is  occasionally 
complicated  by  urticaria,  which  either  imphcates  the  whole 
surface  of  the  body  or  is  localised  to  the  face  and  scalp.  In  the 
latter  case  there  is  usually  much  oedema,  but  httle  or  no  itching. 
The  cutaneous  affection  is  particularly  apt  to  develop  when 
the  gastritis  has  arisen  from  indulgence  in  mackerel,  shell- 
fish, almonds,  mushrooms,  or  pork,  or  from  the  administration 
of  cubebs,  quinine,  salicylate  of  sodium,  and  certain  other 
drugs. 

(2)  The  Febrile  Form. — In  infancy  and  childhood  an  attack 
of  acute  simple  gastritis  is  usually  accompanied  by  slight 
elevation  of  the  temperature,  and  in  certain  cases  a  moderate 
degree  of  fever  persists  during  the  whole  course  of  the  malady. 
In  this  category  are  included  the  various  examples  of  "gastric 


THE    FEBRILE    FORM.  1 59 

fever"  and  "infectious  gastritis"  which  occur  during  epidemics 
of  cholera,  dysentery,  typhoid,  ulcerative  colitis  or  influenza, 
or  that  ensue  from  bacterial  contamination  of  water,  milk 
or  meat.  Delicate  children,  and  those  who  are  predisposed 
by  heredity  to  the  complaint,  will  also  develop  mild  febrile 
gastritis  if  exposed  to  cold,  damp,  or  fog. 

The  onset  of  an  attack  is  usually  indicated  by  pains  in  the 
back  and  limbs,  headache  and  chilliness,  or  slight  rigors,  which 
often  persist  for  several  days,  and  may  be  accompanied  by  an 
eruption  of  herpes  labialis;  but  in  young  children  extreme 
restlessness,  stupor,  rigidity  of  the  neck,  or  even  slight  con- 
vulsions are  sometimes  the  first  indications  of  illness.  The 
temperature  rises  abruptly  and  may  reach  103°  or  104°  F. 
within  a  few  hours;  but  in  adults  the  mercury  seldom  rises 
above  100°  F.  On  the  second  day  the  fever  becomes  markedly 
remittent  and  thence  forward  gradually  subsides  until  it 
finally  disappears  at  the  end  of  seven  to  ten  days.  Occasion- 
ally the  disorder  terminates  by  crisis  on  the  third  or  fourth  day. 
Pain  in  the  abdomen  is  rarely  a  prominent  feature  of  the  case, 
but  a  sense  of  fulness,  heat,  or  oppression  at  the  epigastrium 
is  always  present.  Vomiting  is  less  frequent  than  in  th^r 
afebrile  variety,  and  only  occurs  at  intervals;  nausea,  on  the; 
other  hand,  may  be  extremely  troublesome  and  persistent. 
The  ejecta  contain  an  excess  of  mucus  and  and  are  devoid  of 
free  hydrochloric  acid.  The  pulse  is  small  and  quick,  the 
tongue  is  covered  with  a  thick  white  fur,  and  the  odour  of  the 
breath  is  at  first  offensive  and  subsequently  sweet  from  the 
presence  of  acetone.  As  a  rule,  the  bowels  are  confined,  and 
the  stools  are  pale  and  very  foetid. 

The  fact  that  the  complaint  is  so  often  due  to  an  infection 
of  the  digestive  tract  serves  to  explain  the  frequent  implication 
of  the  duodenum  and  colon.  When  the  former  portion  of  the 
bowel  becomes  affected,  the  skin  acquires  a  sallow  colour  and 
the  conjunctivae  exhibit  an  icteric  tinge.  Drowsiness,  headache, 
and  extreme  lassitude  are  also  prominent  symptoms,  and  the 


l6o  SIMPLE  ACUTE   GASTRITIS. 

stools  become  extremely  offensive  and  are  devoid  of  colour. 
In  the  epidemic  form  of  the  complaint  jaundice  is  a  common 
phenomenon  and  may  persist  for  several  weeks.  Inflamma^ 
tion  of  the  colon  is  characterised  by  the  passage  of  loosel 
offensive  stools  containing  shreds  or  strings  of  mucus  and 
occasionally  streaks  of  blood.  Complaint  is  also  made  of 
frequent  griping  pains  in  the  abdomen  accompanied  by  dis- 
tention, flatus,  and  increased  frequency  of  micturition.  If 
the  appendix  has  been  previously  diseased,  an  acute  attack  of 
appendicitis  may  develop  owing  to  extension  of  the  csecal 
inflammation.  Slight  albuminuria  is  not  uncommon  during 
the  febrile  period  of  the  gastric  complaint,  and  occasionally 
acute  nephritis  supervenes  after  the  lapse  of  a  few  days. 
This  latter  complication  is  chiefly  encountered  in  cases  of  food 
poisoning  and  is  particularly  prone  to  occur  in  the  subjects 
of  syphilis.  In  all  cases,  and  especially  in  young  children, 
loss  of  weight  is  a  noteworthy  feature  of  an  attack  and  often 
seems  quite  disproportionate  to  the  degree  of  local  and  general 
disturbance  engendered  by  the  gastric  disorder.  As  soon, 
however,  as  the  stomach  resumes  its  functional  activity,  flesh 
and  strength  are  regained  almost  as  rapidly  as  they  had 
previously  been  lost.  When  the  submaxillary  or  cervical 
glands  have  been  enlarged  prior  to  the  gastritis,  these  lymphatic 
structures  often  increase  in  size  during  the  febrile  period. 

Diagnosis. — The  diagnosis  of  simple  acute  gastritis  with- 
out fever  does  not  usually  present  much  difficulty.  Children 
are  more  prone  to  disorders  of  digestion  than  to  any  other 
complaint  of  an  afebrile  character,  and  consequently  when 
indigestion  develops  suddenly  during  a  period  of  perfect  health 
and  is  accompanied  by  nausea,  retching,  and  vomiting  of  bile- 
stained  mucus,  the  probabihty  of  acute  inflammation  of  the 
stomach  must  at  once  be  apparent.  This  is  converted  into  a 
certainty  if  it  be  found  that  the  first  ejecta  consist  of  undigested 
remnants  of  a  meal  consumed  many  hours  previously,  mixed 
with  a  large  quantity  of  a  mucoid  fluid  which  contains  organic 


DIAGNOSIS.  l6l 

acids  but  is  devoid  of  free  hydrochloric  acid.  In  many 
instances  also  there  is  either  a  history  of  previous  attacks  of  a 
similar  nature  or  the  present  disorder  can  be  clearly  traced  to 
some  hygienic  or  dietetic  error.  When  headache,  palpitation, 
dyspnoea,  or  giddiness  are  prominent  features  of  the  case,  a 
fear  of  meningitis  is  sometimes  entertained.  Careful  con- 
sideration, however,  will  usually  show  that  these  several 
phenomena  are  merely  secondary  to  the  inflammatory  disorder 
of  the  stomach,  while  the  essential  indications  of  cerebral 
mischief  are  absent.  Migraine  and  acute  gastritis  are  so 
closely  allied  that  in  some  instances  it  may  be  difficult  at  first 
to  differentiate  one  from  the  other.  As  a  rule,  however,  the 
former  complaint  is  much  more  common  after  the  age  of 
puberty  than  in  childhood,  while  enquiry  will  show  that  one  of 
the  parents  or  other  members  of  the  family  have  suffered  in  a 
similar  manner.  Violent  headache,  accompanied  perhaps  by 
various  sensory  phenomena,  constitute  the  earliest  symptoms 
of  migraine  and  tend  to  subside  after  the  emesis  has  commenced, 
while  in  simple  gastritis  epigastric  discomfort,  nausea,  and 
vomiting  are  the  primary  manifestations  and  the  headache  is  of 
secondary  importance.  A  disorder  very  similar  in  its  general 
features  to  migraine  is  also  met  with  in  the  subjects  of  gas- 
troptosis,  but  in  this  instance  the  discovery  of  a  displaced 
stomach  will  at  once  indicate  the  nature  of  the  complaint. 
Acute  hypersecretion  is  the  most  important  disease  from 
which  acute  gastritis  has  to  be  distinguished.  In  both  com- 
plaints nausea,  retching,  and  vomiting  are  prominent  symptoms, 
and  the  inability  to  take  nourishment  by  the  mouth  causes 
rapid  loss  of  flesh  and  strength.  But  it  will  be  remembered,, 
however,  that  acute  hypersecretion  is  merely  an  acute  phase  of  aH't 
chronic  disorder  of  the  stomach  arising  from  an  organic  lesion  | 
of  the  digestive  tract,  and  that  the  vomit,  instead  of  being't 
scanty,  alkaline,  and  composed  of  mucus,  as  in  simple  gastritis,^*^ 
is  abundant,  liquid,  acid,  and  contains  an  excess  of  free 
hydrochloric  acid;  in  fact,  it  is  only  necessary  to  dip  a  piece 


1 62  SIMPLE  ACUTE    GASTRITIS. 

of  congo-red  paper  into  the  ejecta  to  distinguish  between  the 
two  disorders.  The  extreme  severity  of  the  epigastric  pain 
and  the  frequent  existence  of  free  hydrochloric  acid  in  the 
vomit  will  usually  serve  to  differentiate  the  gastric  crises  of 
locomotor  ataxia  from  simple  inflammation  of  the  stomach. 

It  must  never  be  forgotten  that  all  forms  of  chronic  gastritis 
are  liable  to  exhibit  intercurrent  attacks  of  an  acute  kind,  the 
occurrence  of  which  are  apt  to  divert  attention  from  the  renal, 
pulmonary,  splenic,  or  hepatic  complaint  to  which  they  owe 
their  origin  (Chapter  IX). 

The  fact  that  gastritis  accompanies  the  onset  of  scarlatina, 
variola,  and  other  specific  fevers  may  render  the  diagnosis  of 
siraple  febrile  gastritis  a  matter  of  some  difi&culty.  After  the 
expiration  of  twenty-four  hours,  however,  the  absence  of 
characteristic  symptoms  of  the  infectious  disease  coupled 
with  the  remittent  type  of  the  fever  is  usually  sufficient  to 
indicate  the  purely  local  nature  of  the  disorder.  On  the 
other  hand,  there  is  little  doubt  that  mild  cases  of  typhoid 
in  children  are  frequently  regarded  as  "gastric  fever"  owing  to 
the  absence  of  spots  and  the  irregular  form  of  temperature. 
Care  should  always  be  taken,  therefore,  to  eliminate  the 
possibility  of  enteric  fever  by  an  examination  of  the  blood  for 
the  Widal  reaction. 

Prognosis. — The  duration  of  an  attack  of  afebrile  gas- 
tritis is  somewhat  uncertain.  When  the  case  is  seen  at  an 
early  period  of  the  complaint  and  treated  in  an  appropriate 
manner,  it  usually  terminates  in  three  to  five  days;  but  if 
neglected  it  may  be  prolonged  in  a  subacute  form  for  several 
weeks.  It  is  only  when  the  patient  is  debilitated  by  some 
serious  organic  disease  that  the  gastric  affection  can  be  regarded 
as  dangerous  to  life. 

The  febrile  variety  pursues  a  somewhat  longer  course  and 
the  fever  may  not  completely  subside  for  ten  or  twelve  days, 
while  if  complicated  by  jaundice  or  inflammation  of  the  colon 
convalescence  may  be  postponed  for  several  weeks. 


TREATMENT    OF    SIMPLE   ACUTE    GASTRITIS.  163 

Treatment  of  Simple  Acute  Gastritis. — General. — The 
prevention  of  acute  gastritis  in  persons  who  are  predisposed  to 
the  disorder  is  a  matter  of  primary  importance.  In  the  case 
of  young  children  an  attack  is  usually  precipitated  by  exposure 
to  cold  or  fog  or  by  the  ingestion  of  substances  which  are 
either  in  a  state  of  incipient  putrefaction  or  are  unsuitable  to 
the  peculiar  digestive  powers  of  the  individual.  However 
pure  the  milk  may  appear  to  be,  it  is  always  advisable  to 
sterilize  it  at  home,  and  water  should  invariably  be  boiled; 
while  if  the  latter  contains  an  excess  of  calcium  salts,  Salutaris, 
Malvern  water,  or  that  obtained  from  some  natural  spring 
should  be  substituted  for  the  local  supply.  One  of  the  reasons 
why  so  many  persons  suffer  from  acute  gastritis  or  "bilious 
attacks"  when  they  reside  at  certain  places  on  the  east  and 
southeast  coast  of  England  is  that  the  drinking  water  is 
exceptionally  "  hard "  or  "  chalky."  Attention  has  already  been 
drawn  to  the  fact  that  the  epidemic  forms  of  gastroenteritis 
are  almost  invariably  due  to  the  presence  of  pathogenic  organ- 
isms in  the  milk  or  water. 

Excessive  indulgence  in  food  and  overloading  the  stomach 
with  sweets,  fruit,  and  cake  are  apt  to  lead  to  gastrectasis  in 
persons  who  have  already  suffered  from  several  attacks  of 
inflammation  of  the  stomach  and  thus  to  predispose  to  frequent 
recurrences  of  the  complaint.  It  is,  therefore,  advisable  that 
in  such  cases  the  meals  should  be  given  at  regular  intervals 
and  be  composed  of  substances  which  are  least  liable  to  undergo 
fermentation  in  the  stomach.  Care  must  always  be  taken 
to  protect  the  surface  of  the  body  from  rapid  changes  of 
temperature,  and  with  this  view  woollen  underclothing  of 
suitable  thickness  and  warm  stockings  must  be  worn  all  the 
year  round,  with  a  flannel  or  chamois-leather  belt  next  to  the 
skin.  Cold  baths  should  be  avoided  even  in  summer.  The 
fact  that  unusual  excitability  and  buoyancy  of  spirits  often 
precede  an  attack  of  gastritis  in  a  child  constitutes  an  indi- 
cation for  the  administration  of  preventive  treatment  in  the 


164  SIMPLE  ACUTE   GASTRITIS. 

form  of  a  dose  of  calomel  and  a  saline  purge;  while  in  those 
cases  where  undue  excitement  or  fatigue  usually  provokes  the 
disorder,  the  amount  of  outdoor  exercise  must  be  restricted 
and  children's  parties  or  other  forms  of  entertainment  be 
prohibited  for  a  few  years. 

Diet. — An  inflamed  organ  requires  physiological  rest,  and 
an  inflamed  stomach  is  the  best  illustration  of  this  elementary 
law.  Starvation  is  essential  to  the  rapid  cure  of  acute  gastritis, 
and  no  food  should  be  administered  by  the  mouth  for  twenty- 
four  hours  or  even  longer.  In  the  case  of  an  adult  this  absti- 
nence produces  no  ill  effects,  but  in  young  and  debihtated 
children  deprivation  of  nourishment  is  apt  to  increase  the 
exhaustion  produced  by  retching  and  vomiting,  and  it  may, 
therefore,  sometimes  be  necessary  to  administer  nutrient 
enemata  composed  of  peptonised  milk  and  a  few  drops  of 
brandy.  When  thirst  is  excessive  small  pieces  of  ice  may  be 
sucked  at  intervals  or  the  patient  may  be  encouraged  to  drink 
large  quantities  of  hot  water  with  the  view  of  inducing  vomiting 
and  thus  cleansing  the  stomach  of  its  mucous  contents.  It  is 
usually  held  that  cessation  of  sickness  and  the  return  of  appetite 
are  the  indications  for  the  administration  of  food;  but  it  must 
be  borne  in  mind  that  profound  exhaustion  is  itself  productive 
of  anorexia  as  well  as  nausea,  and  that  the  latter  symptom  will 
often  disappear  when  the  patient  forces  himself  to  take  food. 
As  a  rule,  feeding  may  be  commenced  with  impunity  within 
forty-eight  hours  of  the  commencement  of  an  attack,  but  should 
the  stomach  reject  the  nourishment  recourse  must  be  had  to 
rectal  alimentation.  In  such  cases  from  8  to  15  02.  of  pepton- 
ised milk  are  slowly  introduced  into  the  bowel  by  means  of  an 
india-rubber  catheter  and  funnel,  about  forty-five  minutes 
being  required  for  the  performance  of  the  operation.  A  rectal 
douche  of  normal  saline  solution  night  and  morning  prevents 
irritation  of  the  bowel  and  promotes  the  retention  and  absorp- 
tion of  the  milk.  When  the  stomach  is  able  to  retain  food,  iced 
milk,  diluted  with  an  equal  quantity  of  lime-water,  maybe  given 


TREATMENT    OF    SIMPLE   ACUTE    GASTRITIS.  1 65 

in  tablespoonful  doses  every  hour  for  six  hours,  after  which 
time,  if  vomiting  has  not  recurred,  the  dose  may  be  increased 
to  6  oz.  or  more  and  the  proportion  of  lime-water  gradually 
diminished.  In  severe  cases  egg-albumin  mixed  with  water, 
followed  by  iced  whey  should  be  substituted  for  the  milk. 
As  soon  as  the  nourishment  is  retained  with  comfort,  the  diet 
may  be  increased  by  the  addition  of  clear  soups,  bovril,  beef  tea, 
Benger's  food,  toast  and  milk,  lightly  boiled  or  poached  eggs; 
and  subsequently  by  fish,  chicken,  sweetbread,  scraped  meat, 
lean  ham,  etc.  Cooked  meats  and  green  vegetables  should 
be  prohibited  for  at  least  a  week,  and  the  meals  should  remain 
moderate  in  amount  and  be  taken  at  regular  intervals. 

Medicinal. — Acute  simple  gastritis  undergoes  spontaneous 
cure  by  the  operation  of  two  great  natural  factors,  namely, 
the  evacuation  of  the  irritant  contents  of  the  stomach  by 
vomiting,  and  the  period  of  physiological  rest  which  is  imposed 
upon  the  organ  owing  to  the  suppression  of  appetite.  The 
medicinal  treatment  of  the  disease  should  therefore  be  con- 
ducted upon  these  lines.  In  every  case  the  first  consideration 
should  be  the  amount  of  noxious  material  which  is  still  con- 
tained in  the  stomach,  as  shown  by  the  vomit.  Should  emesis 
not  yet  have  commenced,  or  if  the  ejecta  exhibit  traces  of  food, 
the  obvious  indication  is  to  assist  the  stomach  to  rid  itself  of 
its  irritant  contents.  With  this  object  20  grains  of  powdered 
ipecacuanha  may  be  administered  at  once  and  followed  in  a 
few  minutes  by  a  tumblerful  of  hot  water,  while  in  the  case  of  a 
child  10  to  15  minims  of  the  liquid  extract  or  a  dessertspoonful 
or  more  of  the  wine  of  ipecacuanha  may  be  employed.  A 
dose  of  emetine  or  a  hypodermic  injection  of  apomorphine 
finds  favour  with  many  practitioners,  but  they  are  apt  to  prove 
unduly  depressant  to  some  individuals.  Substances  like 
mustard,  tartar  emetic,  sulphate  of  zinc  and  sulphate  of  copper, 
which  cause  vomiting  by  direct  irritation  of  the  mucous  mem- 
brane of  the  stomach,  should  be  avoided  as  they  tend  to  in- 
crease the  existing  inflammation.     Even  after  all  the  decom- 


1 66  SIMPLE  ACUTE    GASTRITIS. 

posing  food  has  been  evacuated,  the  inner  surface  of  the  viscus 
may  still  continue  to  be  irritated  by  the  presence  of  fermenting 
mucus,  the  expulsion  of  which  is  a  matter  of  great  difficulty 
owing  to  its  thick  and  tenacious  character.  Continental 
writers  consequently  advise  that  the  stomach  should  be  washed 
out  with  warm  water  containing  a  small  quantity  of  bicarbonate 
of  sodium  whenever  the  emesis  recurs  at  short  intervals  and 
the  ejecta  consist  of  mucus.  Lavage  is  a  most  excellent  remedy 
and  will  usually  subdue  the  nausea  and  retching  more  quickly 
than  any  other  form  of  treatment;  but  unfortunately  many 
people  object  most  strenuously  to  the  passage  of  the  tube  and 
will  only  submit  to  its  use  when  milder  measures  have  failed 
to  effect  a  cure. 

The  stomach  may  be  cleansed  by  the  propulsion  of  its 
contents  into  the  intestine  as  well  as  by  their  elimination 
through  the  mouth,  and  since  the  time  of  Hippocrates  brisk 
purgation  has  always  been  regarded  as  indispensable  to  the 
cure  of  acute  gastritis. 

In  infants  and  young  children  a  dose  of  castor  oil  or  the 
administration  of  a  castor  oil  mixture  every  three  hours  will 
usually  promote  a  rapid  cure  in  mild  cases;  but  if  vomiting 
is  a  troublesome  feature,  one-third  of  a  grain  of  calomel  given 
every  two  hours  until  free  purgation  has  been  produced  will 
be  found  more  efficacious.  At  a  later  period  of  life  the  same 
method  of  treatment  is  equally  successful,  although  preference 
should  be  given  to  salines  rather  than  to  castor  oil.  As  soon 
as  the  vomit  is  free  from  food  from  3  to  5  grains  of  calomel  or 
a  mercurial  pill  may  he  administered,  followed  after  three 
hours  by  a  seidlitz  powder  or  a  full  dose  of  Carlsbad  salts,^ 
sulphate  of  sodium  or  magnesium,  or  of  phosphate  of  sodium. 
A  tablespoonful  of  a  mixture  composed  of  equal  parts  of  the 
phosphate  and  dried  sulphate  of  sodium  dissolved  in  a 
tumberful  of  hot  water  is  usually  an  excellent  remedy  and 
may  be  repeated  on  the  following  morning. 

It  rarely  happens  that  the  vomiting  continues  after  the  bowels 


ACUTE    TOXIC    GASTRITIS,  1 67 

have  been  thoroughly  evacuated;  but  should  nausea  or  retching 
still  prove  persistent,  a  mixture  of  solution  of  bismuth, 
bicarbonate  of  sodium,  and  dilute  hydrocyanic  acid,  with  or 
without  morphine,  administered  in  an  effervescent  form,  will 
usually  cause  these  symptoms  to  subside.  A  hypodermic  in- 
jection of  morphine  is  seldom  required.  In  the  after-treatment 
of  the  case  it  may  be  necessary  to  repeat  the  mercurial  and 
salines  at  intervals  or  to  prescribe  a  mixture  containing  bicar- 
bonate of  sodium  and  rhubarb  to  be  taken  between  meals. 
Tonics  invariably  disagree  with  the  subjects  of  gastritis,  and 
in  many  cases  the  exhibition  of  these  drugs  either  causes  a 
recrudescence  of  the  acute  symptoms  or  induces  a  subacute 
form  of  the  disease.  Alkaline  remedies,  on  the  other  hand, 
always  agree,  and  if  the  case  shows  a  tendency  to  relapse  they 
may  be  continued  with  advantage  for  several  weeks. 

When  abdominal  pain  is  a  prominent  feature  of  the  com- 
plaint, hot  moist  applications  to  the  abdomen  in  the  form  of 
poultices  or  fomentations  are  of  value,  to  which  turpentine, 
mustard,  or  laudanum  may  be  added  if  considered  desirable. 
Leeching  and  cupping  which  formed  part  of  the  routine 
treatment  of  simple  gastritis  in  former  days,  are  seldom,  if 
ever,  employed  at  the  present  day. 

ACUTE  TOXIC  GASTRITIS. 

Although  in  a  general  sense  all  forms  of  acute  gastritis  are 
toxic  in  origin,  it  is  advisable  from  the  clinical  stand-point  to 
confine  the  term  "  toxic"  to  that  variety  of  severe  acute  gastritis 
which  is  caused  by  the  introduction  into  the  organ  of  certain 
poisonous  substances.  If  it  were  always  remembered  that 
the  sudden  development  of  severe  gastritis  in  a  healthy  in- 
dividual is  invariably  due  to  poison  of  one  kind  or  another, 
many  mistakes  of  diagnosis  would  be  prevented  and  possibly 
not  a  few  attempts  to  murder  might  be  frustrated. 

The  substances  which  most  often  cause  toxic  gastritis  are 
the  concentrated  mineral  acids  and  caustic  alkalies,  carbohc. 


1 68  ACUTE   TOXIC    GASTRITIS. 

oxalic,  and  chromic  acids,  corrosive  sublimate,  alcohol, 
arsenic,  antimony,  phosphorus,  and  the  oxalate  and  cyanide 
of  potassium.  In  a  lesser  degree  all  medicinal  remedies  given 
in  excessive  doses  produce  a  toxic  inflammation  of  the  stomach, 
especially  when  the  patient  happens  to  possess  a  natural 
intolerance  of  them,  while  certain  organic  substances  formed 
by  the  decomposition  of  meat  and  other  nitrogenous  foods  are 
capable  of  inducing  violent  gastroenteritis  when  introduced 
into  the  body. 

Pathology. — Concentrated  mineral  acids  and  carbolic 
acid  dehydrate  and  coagulate  the  tissues  of  the  stomach  with 
the  production  of  an  acute  necrosis.  If  life  be  prolonged  the 
dead  material  eventually  separates  and  the  resultant  ulcer 
gradually  cicatrises.  The  extent  and  severity  of  the  injury 
depends  upon  the  quantity  and  concentration  of  the  poison 
and  the  state  of  the  stomach  at  the  time  of  its  ingestion;  a 
relatively  small  dose  taken  when  the  organ  is  devoid  of  food 
being  more  destructive  than  a  larger  amount  ingested  after  a 
full  meal.  If  the  corrosive  was  swallowed  when  the  patient 
was  in  an  erect  or  sitting  posture  the  fundus  and  great  curva- 
ture of  the  stomach  usually  bear  the  brunt  of  the  mischief, 
but  if  he  happened  to  be  lying  down  the  pharynx  and  oesopha- 
gus are  often  disproportionately  affected.  In  rapidly  fatal 
cases  the  stomach  is  found  after  death  to  contain  much  mucus 
and  altered  blood  and  to  present  general  hyperaemia  and 
swelling  of  its  tissues. 

The  deep  red  colour  of  the  mucous  membrane  is  most 
pronounced  along  the  summits  of  the  rugae,  while  the  sulci 
which  intervene  between  them  may  be  comparatively  un- 
affected owing  to  the  tetanic  contraction  of  the  organ  which 
ensues  from  contact  with  the  irritant.  Scattered  over  the 
fundus  and  along  the  line  of  the  great  curvature  one  or  more 
hard,  dry,  parchment-like  eschars  may  be  observed,  of  a  black, 
gray,  or  yellow  colour  according  to  the  nature  of  the  acid. 
Not  infrequently  a  large  perforation  is  seen  to  exist  at  the  site 


SYMPTOMS.  169 

of  one  of  these  necrotic  areas,  the  edges  of  which  display  a 
characteristic  blackened  and  shreddy  appearance.  The 
islands  or  tracts  of  mucous  membrane  between  the  dead  areas 
are  intensely  red,  swollen,  softened,  and  oedematous  or  super- 
ficially ulcerated,  and  in  some  cases  the  upper  part  of  the 
duodenum  displays  similar  signs  of  acute  inflammation. 

When  life  has  been  prolonged  for  several  months  the 
whole  of  the  inner  surface  of  the  stomach  may  exhibit  a 
pecuhar  striated  and  glistening  appearance  owing  to  the 
replacement  of  the  mucous  membrane  by  a  thin  layer  of 
fibrous  tissue,  while  in  the  vicinity  of  the  pylorus,  and  perhaps 
also  in  the  lower  end  of  the  oesophagus,  an  open  chronic  ulcer 
may  be  visible,  the  repair  of  which  has  been  retarded  by  the 
constant  movement  of  the  sphincters  that  guard  the  orifices. 
In  other  cases,  again,  the  stomach  appears  to  be  dilated, 
puckered,  or  pouched,  owing  to  an  irregular  contraction  of  its 
ulcerated  surface. 

Caustic  alkahes  differ  somewhat  in  their  mode  of  action 
from  acids  in  that  they  liquefy  the  protoplasm  of  the  cells. 
They  consequently  extend  more  deeply  into  the  gastric  tissues 
and  produce  areas  of  necrosis  which  are  softer  and  less  defined 
than  in  the  former  case.  Occasionally  the  affected  portions 
have  the  appearance  of  false  membrane. 

Metalhc  poisons,  of  which  arsenic,  antimony,  and  phos- 
phorus are  the  best  examples,  produce  a  diffuse  form  of 
gastritis,  which  in  the  case  of  the  two  first  named  may  be 
accompanied  by  haemorrhages  into  the  mucous  membrane, 
along  with  vesicles,  pustules,  or  patches  of  ulceration.  Phos- 
phorus, on  the  other  hand,  excites  comparatively  httle  obvious 
inflammation,  but  gives  rise  to  fatty  degeneration  of  the  gastric 
glands,  with  subsequent  atrophy,  and  a  similar  result  some- 
times occurs  in  alcoholic  and  arsenical  gastritis. 

Sj^mptoms. — The  ingestion  of  the  corrosive  is  followed 
immediately  by  a  violent  burning  pain  which  extends  from  the 
pharynx  to  the  epigastrium.     Vomiting  ensues  within  a  short 


170  ACUTE   TOXIC    GASTRITIS. 

time  attended  by  violent  retching  and  the  rejection  of  blood- 
stained mucus,  and  even  shreds  of  mucous  membrane.  The 
face  is  pale,  drawn  and  anxious,  the  forehead  is  covered  by  a 
cold  sweat,  and  the  lips  and  extremities  are  usually  cyanotic. 
The  pulse  is  accelerated,  small  and  of  low  tension,  and  the 
respiration  is  quick,  shallow  and  almost  entirely  thoracic. 
In  severe  cases  collapse  is  a  prominent  symptom  from  the 
outset,  and  after  a  short  interval  perforation  of  the  stomach 
with  general  peritonitis  may  supervene.  The  abdomen  is 
retracted,  motionless  on  respiration,  and  extremely  tender  to 
pressure  over  its  upper  half. 

The  course  of  the  complaint  varies  according  to  the  nature 
of  the  poison  and  the  quantity  swallowed.  If  the  mischief 
is  chiefly  confined  to  the  oesophagus,  the  vomiting  may  sub- 
side within  a  few  hours  and  the  patient  may  even  have  a 
desire  for  food.  In  a  case  of  alkali  poisoning  which  came 
under  my  notice,  the  patient  expressed  himself  as  perfectly 
well  at  the  end  of  twenty-four  hours,  drank  milk  with  avidity, 
and  complained  of  being  deprived  of  solid  food.  Nevertheless, 
on  the  sixth  day  he  suddenly  vomited  an  oesophageal  slough 
measuring  5J  inches  long  by  i^  inches  in  breadth  and 
which  included  the  greater  part  of  the  muscular  coat  of  the 
tube.  At  his  death  six  months  afterward  the  oesophagus  was 
found  to  be  represented  by  a  twisted  fibrous  cord.  When  the 
stomach  has  been  extensively  damaged  without  immediate 
death,  the  pain  and  vomiting  gradually  subside,  and  after 
the  lapse  of  a  variable  period  the  patient  is  able  to  take  semi- 
solid food.  As  a  rule,  however,  he  suffers  constantly  from 
discomfort,  distention,  and  flatulence  after  meals,  with  trouble- 
some constipation,  or  displays  symptoms  characteristic  of 
gastric  ulcer.  Atrophy  of  the  gastric  mucosa  is  accompanied 
by  an  intractable  dyspepsia  and  the  disappearance  of  free 
hydrochloric  acid  and  pepsin  from  the  secretion.  Cicatri- 
sation of  an  ulcer  near  the  pylorus  produces  the  symptoms 
and  signs  of  pyloric  stenosis,  while  occulsion  of  the  cardiac 


TREATMENT.  I7I 

orifice  from  a  similar  cause  is  attended  by  the  indications  of 
oesophageal  stricture.  It  is  an  interesting  fact  that  destruction 
of  the  gastric  mucosa  by  mineral  acids  is  often  followed  by 
acute  phthisis  (Fenwick). 

Sulphuric,  nitric,  chromic,  formic,  and  oxalic  acids  are 
very  apt  to  give  rise  to  secondary  inflammation  of  the  kidneys, 
and  sometimes  to  anuria. 

Diagnosis. — The  sudden  onset  of  violent  gastric  symp- 
toms in  a  healthy  individual  must  always  suggest  an  acute 
toxic  gastritis,  and  in  most  instances  enquiries  will  elicit  the 
nature  of  the  poison.  In  other  cases,  the  appearance  of  the 
mouth  and  throat  or  the  characters  of  the  vomit  will  indicate 
the  irritant  that  has  been  swallowed.  In  every  case  the 
vomit  should  be  collected  and  submitted  to  a  careful  analysis. 
For  the  symptoms  characteristic  of  the  different  forms  of 
poisons  the  reader  must  be  referred  to  the  text-books  on 
toxicology. 

Treatment. — Vomiting  rarely  removes  all  the  poison 
which  has  gained  access  to  the  stomach,  and  consequently 
whenever  it  is  possible,  steps  should  immediately  be  taken  to 
wash  out  the  viscus.  No  tube  should  ever  be  passed  down  the 
oesophagus  when  there  is  reason  to  suppose  that  mineral 
acids,  caustic  alkalies,  or  carbolic  acid  have  been  swallowed, 
or  when  excessive  pain  or  haemorrhage  indicate  that  consider- 
able damage  has  already  been  inflicted  upon  the  oesophagus 
or  stomach.  For  the  antidotal  treatment  of  the  various  irritants, 
the  reader  must  again  be  referred  to  a  treatise  upon  poisons. 
The  after-treatment  of  the  case  is  essentially  the  same  as  that 
adopted  in  severe  cases  of  simple  gastritis.  As  regards  the 
consequences  of  the  disease,  oesophageal  stricture  will  probably 
have  to  be  subjected  to  gastrostomy,  stenosis  of  the  pylorus, 
to  daily  lavage,  and  eventually  to  gastro-enterostomy,  while 
general  atrophy  of  the  stomach  must  be  treated  on  the  same 
lines  as  those  laid  down  for  other  forms  of  that  complaint. 


172  CHRONIC   GASTRITIS. 

(2)     CHRONIC  GASTRITIS. 

It  is  a  universal  belief  among  medical  practitioners  that 
chronic  inflammation  of  the  stomach  is  one  of  the  most 
frequent  causes  of  indigestion,  and,  indeed,  is  responsible  for 
the  majority  of  the  cases  in  which  pain  or  discomfort  after 
food  cannot  be  attributed  either  to  atony,  cancer,  or  ulcer. 
The  term  "catarrh"  or  "chill"  of  the  stomach  has  conse- 
quently attained  an  important  place  in  the  nomenclature  of 
gastric  diseases  and  is  considered  by  the  lay  mind  to  explain 
the  origin  of  almost  every  symptom  arising  from  a  disorder  of 
the  digestive  organs.  As  a  matter  of  fact,  however,  the 
systematic  examination  of  the  stomach  by  modern  methods  has 
incontestably  proved  what  isolated  writers  have  asserted  for 
many  years,  namely,  that  chronic  gastritis,  except  when  due 
to  the  abuse  of  alcohol,  is  a  comparatively  rare  complaint,  and| 
almost  always  indicates  serious  organic  disease  of  some  im- 
portant organ  of  the  body.  Instead  of  being  regarded,  there-i 
fore,  as  a  disorder  of  little  importance  and  of  easy  recognition, 
a  diagnosis  of  chronic  gastritis  should  never  be  made  without 
considerable  hesitation  and  a  thorough  knowledge  of  its 
significance.  Among  my  thousand  cases  of  dyspepsia,  chronic 
gastritis  was  found  to  be  responsible  for  the  symptoms  in 
14.4  per  cent,  of  those  treated  in  hospital,  and  in  12 . 4  per  cent, 
of  those  observed  in  private  practice. 

Etiology. — Although  chronic  gastroenteritis  is  an  extremely 
common  complaint  among  the  children  of  the  poor  (Chapter 
VIII),  simple  inflammation  hmited  to  the  stomach  is  practically 
never  encountered  until  after  the  age  of  five,  and  is  rare  until 
puberty.  From  about  thirty  years  onward  it  steadily  increases 
in  frequency  and  is  one  of  the  commonest  causes  of  the  dys- 
pepsia of  old  age.  Males  are  far  more  prone  to  suffer  from  it 
than  females,  the  ratio  of  the  two  sexes  in  my  statistics  being 
nearly  7  to  3.  Some  authorities  consider  that  heredity  exerts 
a  notable  influence  on  its  incidence,  but  it  would  seem  more 
probable   that   the   inheritance   of   gastric   myasthenia   or   a 


ETIOLOGY.  173 

congenital  weakness  of  the  gastric  ligaments  which  produces 
gastroptosis  are  of  greater  etiological  importance.  The 
disease  may  either  appear  as  a  primary  affection  of  the  stomach 
or  it  may  develop  as  the  result  of  organic  mischief  of  the 
stomach  itself  or  of  some  other  viscus.  The  two  varieties 
occur  with  almost  equal  frequency,  the  primary  form  con- 
stituting 45  per  cent,  and  the  secondary  47  per  cent,  of  the 
cases  that  I  investigated.  In  the  remaining  8  per  cent,  the 
origin  of  the  complaint  could  not  be  determined. 

Primary  Chronic  Gastritis. — This  variety  rarely  ensues 
from  the  simple  acute  form,  but  it  is  an  invariable  result  of 
destruction  of  portions  of  the  mucous  membrane  by  corrosives 
and  other  poisons.  Injudicious  alimentation  is  usually  held 
to  be  responsible  for  the  majority  of  the  cases  of  chronic 
gastritis  met  with  during  the  first  three  decades  of  life,  and  may 
undoubtedly  give  rise  to  the  complaint  if  persisted  in  for  a  long 
period  of  time.  Frequent  overloading  of  the  stomach  with 
indigestible  or  fermentable  articles  of  food  is  particularly 
pernicious,  and  its  effects  are  considerably  enchanced  by  a 
rapid  growth  of  the  body.  Young  adults  who  from  habit  or 
necessity  consume  their  food  hurriedly  are  especially  apt  to 
fall  victims  to  the  complaint  as  also  are  those  who  are  unable 
to  masticate  properly  owing  to  deficient  or  defective  teeth. 
In  such  cases  the  large  masses  of  food  which  find  their  way  into 
the  stomach  prove  difficult  of  solution  by  the  gastric  juice, 
and  becoming  stagnant  in  the  viscus  act  as  irritants.  In  like 
manner  the  hasty  swallowing  of  farinaceous  materials  prevents 
their  due  incorporation  with  saliva  and  favours  subsequent 
fermentation.  But  of  all  the  exciting  causes  of  the  disease,  the 
frequent  ingestion  of  substances  that  possess  toxic  properties 
is  by  far  the  most  important.  Thus  in  my  series  of  obser- 
vations it  was  found  that  the  constant  abuse  of  alcohol  was 
responsible  for  no  less  than  60  per  cent',  of  all  cases  of  primary 
chronic  gastritis,  the  percentage  being  larger  in  private  than 
in  hospital  practice  owing  to  the  greater  proportion  of  spirit 


174  CHRONIC   GASTRITIS. 

drinkers  met  with  among  the  wealthier  classes.  Occasionally 
eau  de  cologne  and  other  scents  and  even  methylated  spirit 
are  responsible  for  the  production  of  the  disease.  Next  to 
alcohol,  tobacco  is  probably  the  most  frequent  cause  of  the 
complaint.  Chewers  of  the  weed  are  more  prone  to  suffer 
than  ordinary  smokers,  but  the  habit  of  inhalation  is  almost 
as  deleterious.  In  many  cases  where  I  have  been  puzzled 
to  explain  the  existence  of  chronic  gastritis  in  woman,  the 
patient  has  eventually  confessed  to  excessive  indulgence  in 
tobacco  inhalation.  Idiosyncrasy  plays  an  equally  important 
part  in  the  production  of  chronic  toxic  gastritis  as  in  that  of 
other  diseases,  and  a  dosage  of  alcohol,  tobacco  or  other  drug 
which  has  little  or  no  deleterious  influence  upon  one  individual 
will  induce  severe  gastric  inflammation  in  another.  The 
long-continued  administration  of  certain  medicinal  remedies, 
such  as  cubebs,  copaiba,  sandalwood  oil,  arsenic,  silver, 
mercur}',  quinine,  iodides  and  salicylates,  nitroglycerin,  etc., 
is  occasionally  responsible  for  an  intractable  gastritis,  the  origin 
of  which  may  escape  notice  unless  particular  enquiries  are 
directed  to  the  subject.  The  dyspepsia  which  so  often  follows 
severe  gonorrhoea  is  almost  always  due  to  sandalwood  oil 
or  other  remedy  which  the  patient  has  taken  upon  his  own 
initiative.  The  abuse  of  purgatives  has  always  been  held  to 
produce  chronic  inflammation  of  the  stomach,  but,  according 

(to  my  experience,  the  various  saline  aperients  should  be 
excepted  from  this  indictment.  Strong  tea  and  coffee  pro-' 
duce  gastritis  in  certain  individuals,  while  highly  spiced  foods, 
condiments,  sauces,  and  pickles  certainly  exaggerate,  if  they 
do  not  excite,  the  inflammatory  process.  According  to  Amer- 
ican writers,  the  habit  of  taking  large  quantities  of  ice-water  is 
responsible  for  its  undue  prevalence  in  the  United  States. 

Secondary  Chronic  Gastritis. — Chronic  gastritis  almost  in- 
variably complicates  such  diseases  of  the  stomach  as  cancer, 
sarcoma,  simple  ulcer,  myasthenia,  gastroptosis,  hyper- 
secretion and  lardaceous  degeneration,  and  is  directly  respon- 


ETIOLOGY.  175 

AN  ANALYSIS  OF  ONE  HUNDRED  AND  FIFTY  CASES  OF 

CHRONIC  GASTRITIS,  SHOWING  THE  RELATIVE 

FREQUENCY  OF  ITS  VARIOUS   CAUSES. 


Primary  form 
(45  per  cent.) 

Secondary  form 
(47  percent.) 

Cause  unde- 
termined 
(8  per  cent.) 

Alcohol  .... 

Errors    of    diet 
and     mastica- 
tion  

Drugs 

Tobacco  .... 

Per  cent. 
60 

17.9 

13-3 
8.8 

Disease  of  lungs 

Disease     of     kidneys     and 
bladder 

Long-standing  gastric  my- 
asthenia   

Diseases  of  heart 

Portal  obstruction 

Anaemia,     leucaemia,     dia- 
betes   

Rheumatism 

Septic  states  of  mouth,  etc. 

Per  cent. 
27.6 

21.4 

18 
12.8 
6 

6 
4.2 

4 

100. 0 

100. 0 

sible  for  many  of  the  more  prominent  symptoms  that  accom- 
pany these  various  conditions.  In  such  cases  little  difficulty 
exists  in  determining  the  nature  of  the  primary  disease  and  of 
ascribing  the  inflammatory  trouble  to  its  proper  cause.  Quite 
different,  however,  is  the  aspect  presented  by  chronic  gastritis 
when  it  arises  from  disease  of  an  organ  remotely  situated  from 
the  stomach.  Thus,  in  many  cases  of  phthisis  the  symptoms 
of  the  secondary  gastritis  overshadow  or  even  completely 
replace  those  arising  from  the  pulmonary  complaint,  while  in 
certain  diseases  of  the  urinary  tract  much  experience  and 
discrimination  are  often  required  to  demonstrate  the  connection 
between  an  apparently  trifling  affection  of  the  kidneys  or 
bladder  and  an  intractable  form  of  dyspepsia  (Chapter  IX). 

In  my  statistics,  diseases  of  the  lungs  and  urinary  organs 
together  were  responsible  for  nearly  one-quarter  of  all  the 
cases  of  chronic  gastritis. 


176  CHRONIC   GASTRITIS. 

Of  the  pulmonary  complaints,  phthisis  with  cavitation, 
bronchiectasis,  and  chronic  empyema  are  most  frequently 
complicated  by  gastric  inflammation,  and  in  each  of  these 
diseases,  it  will  be  observed  that  septic  absorption  is  a  promi- 
nent phenomenon.  As  the  result  of  some  experiments  I  was 
able  to  prove  that  the  expectoration  in  chronic  phthisis  con- 
tains an  albuminous  substance  which  when  injected  sub- 
cutaneously  into  animals  produces  a  severe  gastroenteritis. 
It  is  probable,  therefore,  that  the  inflammation  of  the  digestive 
tract  v/hich  so  frequently  accompanies  purulent  diseases  of  the 
lungs  and  pleurae  is  due  to  an  autointoxication.  In  chronic 
Bright's  disease  the  mucous'  membrane  of  the  stomach  and 
intestines  help  to  eliminate  the  urea  and  other  products  of 
metabolism  that  are  retained  in  the  blood,  but  in  so  doing 
the  peptic  and  intestinal  glands  fall  victims  to  their  own 
abnormal  activity  and  become  affected  by  chronic  inflam- 
mation (Chapter  IX).  The  same  result  ensues,  though  in  a 
lesser  degree,  from  deficient  elimination  of  the  urine  owing  to 
enlargement  of  the  prostate,  pressure  upon  the  ureters,  stricture 
of  the  urethra,  or  pyelitis. 

In  about  19  per  cent,  of  the  secondary  cases  the  gastritis 
was  found  to  depend  upon  chronic  venous  congestion  of  the 
stomach  induced  either  by  failure  of  the  heart  (12 .8  per  cent.) 
or  by  obstruction  of  the  portal  vein  (6  per  cent.).  The  per- 
sistent engorgement  of  the  gastric  mucous  membrane  which 
results  from  these  conditions  not  only  diminishes  the  vitality 
of  the  tissues,  but,  by  adversely  affecting  both  secretion  and 
motility,  induces  stagnation  and  fermentation  of  the  food 
with  consequent  irritation  of  the  inner  surface  of  the  viscus. 
This  category  also  includes  the  gastritis  which  arises  from 
failure  of  the  right  side  of  the  heart  in  cases  of  emphysema, 
interstitial  pneumonia,  and  other  diseases  which  embarrass  the 
pulmonary  circulation. 

In  18  per  cent,  of  the  cases  long-standing  myasthenia, 
either  primary  or  secondary,  was  responsible  for  the  symptoms 


PATHOLOGY.  177 

of  chronic  gastric  inflammation;  while  in  6  per  cent,  diabetes 
or  some  disorder  of  the  blood,  such  as  anaemia,  leucaemia,  or 
purpura,  appeared  to  be  its  exciting  cause.  Finally  it  may  be 
mentioned  that  in  4.2  per  cent,  the  gastric  disease  was  attrib- 
uted, either  rightly  or  wrongly,  to  the  presence  of  severe 
rheumatism,  and  in  another  4  per  cent,  to  septic  states  of  the 
mouth  or  nares. 

Pathology. — The  stomach  is  usually  found  after  death 
to  be  somewhat  dilated,  and  its  inner  surface  covered  by  a 
thick  layer  of  mucus,  which  is  particularly  abundant  and  tough 
in  the  pyloric  half  of  the  organ.  When  this  has  been  removed, 
the  mucous  membrane  presents  a  curious  slate-grey  or  brown- 
ish-black pigmentation,  which,  when  examined  through  a 
lens,  is  seen  to  consist  of  numerous  fine  black  dots.  In  the 
central  and  cardiac  portions  of  the  viscus,  in  addition  to  signs 
of  postmortem  digestion,  there  is  always  some  degree  of  super- 
ficial vascularity,  while  not  infrequently  the  surface  is  studded 
with  punctiform  haemorrhages  or  haemorrhagic  erosions. 
The  coats  of  the  organ  are  always  much  thickened,  and  the 
mucous  membrane  may  be  peeled  off  the  subjacent  muscular 
tissue  in  the  form  of  large  strips  of  leathery  consistence.  In 
the  pyloric  region  the  various  coats  are  often  so  closely  welded 
together  as  to  be  indistinguishable  one  from  another.  Occa- 
sionally, the  mucosa  in  the  vicinity  of  the  pylorus  is  beset  by  a 
number  of  minute  elevations  arranged  in  the  form  of  patches 
or  streaks,  and  in  rare  instances  the  whole  of  the  interior  of  the 
stomach  is  affected  in  a  similar  manner.  Sometimes  these 
excrescences  attain  a  considerable  size,  and  form  hemispherical 
or  polypoid  tumours  attached  to  the  surface  by  short  stalks. 
This  abnormal  condition  (the  "^tat  mamelonne"  of  Louis)  is 
due  to  the  contraction  of  the  newly  formed  fibrous  tissue 
situated  between  the  peptic  glands  and  a  hyperplasia  of  the 
glandular  elements.  Another  result  of  chronic  gastritis  is  a 
peculiar  honeycombed  appearance  of  the  mucous  membrane, 
to  which  Trousseau  gave  the  name  of  "I'estomac  a  cellules." 


178  CHRONIC    GASTRITIS. 

In  this  condition  the  inner  surface  of  the  organ  presents 
numerous  little  pits  separated  from  one  another  by  narrow 
ridges  of  pigmented  tissue  or  fine  fibrous  bands,  and  thus 
closely  resembles  the  interior  of  the  urinary  bladder  in  a  case 
of  chronic  cystitis. 

The  microscopic  appearances  vary  considerably  according 
to  the  causation  and  the  duration  of  the  complaint.  As  a  rule, 
the  superficial  epithelium  is  represented  by  clumps  of  granular, 
shrunken,  distorted  or  vacuolated  cells,  while  that  which  lines 
the  mouths  of  the  ducts  shows  a  great  excess  of  the  goblet 
variety.  The  glands  themselves  are  swollen,  tortuous,  and  in- 
distinct in  outline,  and  frequently  exhibit  cystic  dilation  of  their 
blind  extremities.  The  parietal  and  peptic  cells  are  indis- 
tinguishable from  one  another,  their  nuclei  are  obscured,  and 
the  lumina  of  the  tubes  are  blocked  by  granular  debris  and 
particles  of  fat.  In  all  cases  the  interglandular  connective 
tissue  is  more  or  less  densely  infiltrated  by  small  round  cells, 
among  which  may  be  recognised  red  blood  corpuscles  and 
newly  formed  spindle  cells.  The  small  blood  vessels  which 
ramify  between  the  glands  and  in  the  submucosa  are  much 
dilated,  and  here  and  there  recent  extravasations  of  blood  may 
be  detected.  The  intermuscular  connective  tissue  is  also 
affected  by  a  round-cell  infiltration. 

With  the  progress  of  the  disease  the  inflammatory  ex- 
udation between  the  glands  undergoes  gradual  organisation, 
with  the  result  that  the  tubules  become  pressed  upon,  twisted 
and  occluded  so  that  they  either  disappear  altogether  from 
the  section  or  are  represented  by  a  series  of  minute  cysts 
lined  by  a  single  layer  of  columnar  epithelium.  A  similar 
process  in  the  submucous  coat  leads  to  the  formation  of  dense 
fibrous  tissue  with  compression  and  destruction  of  the  strands 
of  muscle  tissue;  while  in  the  middle  coat  of  the  organ  pro- 
gressive thickening  of  the  septa  produces  an  initial  hyper- 
trophy, followed  by  atrophy  and  finally  by  a  fibrosis  of  the 
contractile  structure.     This  short  sketch  is  sufficient  to  indicate 


SYMPTOMS.  179 

that  chronic  inflammation  of  the  stomach  sooner  or  later  affects 
both  the  interstitial  and  the  glandular  elements  of  the  mucous 
membrane,  compressing  and  destroying  the  latter,  and  finally 
leading  to  partial  destruction  of  the  muscular  coat. 

Symptoms. — The  disease  usually  develops  in  an  insidious 
manner  and  several  months  may  elapse  before  the  character- 
istic symptoms  make  their  appearance.  Occasionally,  how- 
ever, it  commences  in  a  more  abrupt  fashion  by  an  attack  of 
acute  or  subacute  gastritis,  which  instead  of  subsiding  gradually 
merges  into  the  chronic  disorder. 

When  fully  developed  the  complaint  presents  a  series  of 
symptoms  which,  considered  in  their  entirety,  are  extremely 
characteristic.  Discomfort  rather  than  pain  is  experienced 
during  the  periods  of  gastric  digestion,  and  is  attended  by 
abdominal  distention,  eructations  of  gas  or  of  acid  fluid, 
nausea,  and  extreme  lassitude.  Vomiting  may  occur  at  inter- 
vals, and  is  especially  common  in  the  early  morning  when  a 
violent  attack  of  retching  culminates  in  the  expulsion  of  a 
little  stringy  or  glairy  mucus  from  the  stomach.  The  bowels 
are  confined  or  irregular  in  their  action,  and  there  is  a  constant 
feeling  of  oppression  in  the  head,  physical  and  mental  ex- 
haustion, and  depression  of  spirits,  accompanied,  as  a  rule,  by 
thirst,  diminution  of  appetite,  and  an  unpleasant  taste  in  the 
mouth.  The  facial  expression  is  anxious  and  careworn,  and 
the  sallow,  wrinkled  condition  of  the  skin  gives  the  individual 
an  appearance  of  premature  age. 

Epigastric  discomfort  is  an  important  symptom  in  every  case 
and  the  one  upon  which  most  stress  is  usually  laid.  As  a  rule, 
it  takes  the  form  of  an  unpleasant  weight  or  fulness  in  the 
region  of  the  stomach  which  ensues  about  an  hour  after  a  meal 
and  causes  the  patient  to  feel  distended  or  bloated.  It  is 
often  associated  with  an  aching  or  dragging  sensation  between 
the  shoulders  or  pain  in  the  throat  or  muscles  of  the  neck. 
The  intensity  of  the  symptom  varies  according  to  the  com- 
position of  the  meal.     Liquids  usually  cause  less  discomfort 


l8o  CHRONIC   GASTRITIS. 

than  solids  and  small  quantities  of  food  of  a  digestible  nature 
agree  better  than  a  large  repast  consisting  of  meat  or  vege- 

(  tables.  The  fact  that  a  dose  of  alcohol  or  other  diffusible! 
stimulant  affords  immediate  relief  is  one  of  the  reasons  why  a| 
sufferer  from  chronic  gastritis  so  frequently  becomes  addictea 
to  overindulgence  in  spirits,  even  though  formerly  he  had  been 
most  temperate  in  this  respect. 

Discomfort  during  the  progress  of  digestion  is  also  a  com- 
mon symptom  of  gastric  myasthenia  and  neurasthenia,  but 
in  these  disorders  it  usually  develops  immediately  after  the 
meal  and  is  aggravated  rather  than  relieved  by  a  liquid  diet. 
The  absence  of  true  pain  in  uncompHcated  chronic  gastritis 
serves  to  distinguish  the  complaint  from  ulcer  of  the  stomach, 
hypersecretion,  and  the  painful  neuroses. 

Nausea  is  a  frequent  but  by  no  means  invariable  symptom 
and  is  more  common  in  women  than  in  men.  In  its  most 
distressing  form  it  occurs  in  the  early  morning  when  it  is  often 
accompanied  by  faintness  or  vertigo,  but  is  immediately 
relieved  by  vomiting.  It  is  also  apt  to  ensue  two  or  three 
hours  after  a  meal  or  it  may  only  develop  when  the  stomach 
is  devoid  of  food.  In  the  latter  case  the  feeling  of  sickness 
is  sometimes  replaced  by  one  of  sinking  or  depression  at  the 
epigastrium  or  by  severe  giddiness.  As  a  rule,  the  Hability 
to  nausea  and  vomiting  vary  in  inverse  ratio;  persons  who 
vomit  easily  suffering  but  httle  from  nausea,  while  those  who 
only  empty  their  stomachs  with  difficulty  experience  an 
inordinate  sense  of  sickness. 

Vomiting  is  a  variable  symptom  of  chronic  gastritis  and 
is  most  frequently  observed  when  the  disease  is  due  to  the 
abuse  of  alcohol  or  other  toxic  poison.  In  its  most  char- 
acteristic form  it  occurs  in  the  early  morning  when  the  patient 
rises  from  bed  and  is  usually  preceded  by  nausea,  giddiness, 
or  faintness.  A  violent  attack  of  retching  terminates  in  the 
expulsion  of  a  small  quantity  of  thick,  ropy  mucus,  which  is 
so  tenacious  that  it  has  to  be  dragged  from  the  mouth  by  the 


SYMPTOMS.  151 

fingers.  This  so-called  vomitus  matutinus  consists  partly  of 
mucus  secreted  by  the  inflamed  stomach  and  partly  of  saliva 
that  has  been  swallowed  during  the  night,  mixed  perhaps  with 
a  small  quantity  of  yellow  bile.  Although  most  frequent  in 
alcoholic  gastritis,  a  similar  form  of  vomit  is  also  observed  in 
that  due  to  chronic  renal  disease,  pregnancy,  and  chronic 
phthisis,  but  in  the  last-named  the  act  of  emesis  is  always 
excited  by  a  fit  of  coughing. 

Vomiting  also  ensues  occasionally  during  the  day,  and  in 
the  later  stages  of  alcoholic  gastritis  this  form  of  emesis  is  of 
frequent  occurrence.  An  unduly  large  meal  or  one  that  con- 
sists principally  of  solid  food  is  particularly  apt  to  be  rejected. 
This  symptom  usually  subsides  when  the  patient  is  confined 
to  bed  and  only  partakes  of  liquid  nourishment. 

The  vomit  obtained  after  meals  is,  in  its  way,  quite  as 
characteristic  as  the  vomitus  matutinus.  Rather  abundant 
in  quantity,  it  presents  the  appearance  of  a  sHmy  mass  con- 
taining numerous  pieces  of  food  which  exhibit  no  signs  of 
digestion.  The  mucus  is  uniformly  distributed  throughout 
the  ejecta  and  each  particle  of  meat  or  bread  is  completely 
coated  with  the  viscid  material.  These  features  serve  at  once 
to  distinguish  mucus  secreted  by  the  stomach  from  that 
produced  by  the  throat,  nose,  or  larynx  and  subsequently 
swallowed,  since  the  latter  appears  in  the  form  of  balls  of  a 
glassy  or  purulent  character  which  float  about  in  the  liquid. 
Normal  gastric  juice  digests  mucus  with  difficulty,  and  when 
the  hydrochloric  acid  is  deficient  in  amount,  the  mucus  secreted 
by  the  stomach  tends  to  swell  and  to  become  glairy.  It  has 
been  shown  by  Schmidt  that  the  quantity  of  mucus  secreted  is 
inversely  proportionate  to  the  amount  of  hydrochloric  acid 
present  in  the  gastric  juice;  consequently  excess  of  mucus  in 
the  vomit  always  suggests  a  diminution  of  the  gastric  secretion. 
Although  acid  in  reaction,  the  total  acidity  of  the  filtered  vomit 
is  always  much  diminished,  free  hydrochloric  acid  is  absent, 
and    both    the  combined   acid   and  the   total   chlorides   are 


l82  CHRONIC   GASTRITIS. 

reduced  in  amount.  Lactic  acid  is  rarely  encountered  in 
primary  chronic  gastritis. 

Flatulence  is  always  a  prominent  symptom,  and  large 
quantities  of  gas  are  eructated  at  intervals  during  the  progress 
of  digestion.  The  gas  consists  principally  of  carbon  dioxide, 
mixed  with  varying  amounts  of  nitrogen,  hydrogen,  and 
methane.  Flatulent  distention  of  the  intestines  with  the 
intermittent  passage  of  large  quantities  of  flatus  is  a  very 
distressing  symptom  in  some  cases. 

Regurgitations  of  sour  fluid  or  of  particles  of  acid  food 
is  a  common  source  of  complaint,  but  true  pyrosis,  which 
is  due  to  the  passage  of  a  hyperchloracid  gastric  juice  into 
the  oesophagus  and  pharynx  is  never  encountered.  On  the 
other  hand,  waterbrash  is  by  no  means  an  infrequent  symp- 
tom of  chronic  gastritis,  the  regurgitant  fluid  possessing  an 
insipid  or  slightly  saline  taste  and  a  neutral  reaction.  It  is 
usually  preceded  by  a  cramping  or  stabbing  pain  in  the  left 
hypochondrium. 

The  appetite  is  usually  diminished,  especially  in  the 
primary  variety,  but  it  is  sometimes  very  capricious  and  a 
strong  inclination  may  be  expressed  toward  certain  highly 
spiced,  salt,  or  acid  articles  of  diet.  In  other  instances  a 
feehng  of  sinking  in  the  region  of  the  stomach  is  experienced 
comparatively  soon  after  a  meal,  or  an  apparent  appetite  is 
allayed  by  the  ingestion  of  a  few  mouthfuls  of  food. 

Thirst  is  often  a  conspicuous  symptom,  especially  during 
the  night  and  between  meals,  while  occasionally  a  patient  will 
imbibe  large  quantities  of  fluid  at  short  intervals  with  the  view 
of  allaying  the  sense  of  epigastric  exhaustion  or  of  internal 
heat  from  which  he  constantly  suffers. 

The  breath  is  sickly  and  offensive  and  a  disgusting  taste 
in  the  mouth  may  be  experienced  upon  rising  from  bed  in  the 
morning.  When  a  foul  odour  of  the  breath  ensues  only  at  the 
height  of  gastric  digestion,  it  is  usually  the  result  of  an  abnormal 
putrefaction  of  the  food,  but  if  it  be  permanent  it  is  often 


SYMPTOMS.  183 

due  to  chronic  inflammation  of  the  throat,  nose,  or  mouth.^ 
Ah  excessive  flow  of  saliva  is  not  uncommon,  particularly  at 
night,  when  it  dribbles  from  the  mouth  during  sleep  and  soaks 
the  pillow. 

The  state  of  the  tongue  varies  according  to  the  cause  of  the 
gastritis.  In  the  alcoholic  variety  it  is  usually  moist,  flabby, 
covered  with  a  greyish-yellow  mucus  and  indented  along  its 
margins  by  the  teeth;  or  the  thick  yellowish  coating  is  confined 
to  the  posterior  half  of  the  organ,  the  anterior  portion  being 
clean,  red,  and  pointed.  A  dry,  clean  tongue  frequently 
accompanies  the  gastritis  of  renal  disease,  while  in  the  other 
secondary  forms  of  the  complaint  the  organ  presents  no 
characteristic  appearance. 

The  heart's  action  is  slow,  feeble,  or  even  irregular,  and 
with  the  progress  of  emaciation  the  pulse  loses  tone  and  tends 
to  increase  in  frequency. 

In  the  early  stages  of  the  complaint  the  bowels  are  usually 
confined  and  the  stools  are  pale,  hard,  scybalous,  coated  with 
mucus,  and  extremely  offensive. 

Subsequently,  diarrhoea  is  apt  to  alternate  with  periods  of 
constipation,  when  several  liquid,  pultaceous,  or  frothy  motions 
are  voided  in  quick  succession,  attended  by  much  flatus  and 
griping  pains  in  the  abdomen.  Piles  often  exist  before  any 
enlargement  of  the  fiver  can  be  detected. 

The  urine  is  diminished  in  quantity  and  deposits  urates  or 
oxalates  on  standing. 

The  nervous  system  participates  markedly  in  the  general 
disturbance.  Constant  lassitude,  an  inabifity  to  concentrate 
the  attention,  impairment  of  memory,  and  excessive  restlessness 
or  irritability  are  frequently  observed.  In  other  cases  vertigo, 
curious  sensations  of  fear  during  the  periods  of  digestion, 
mental  depression,  or  even  hypochondriasis  are  prominent 
features  of  the  case.  Many  patients  suffer  constantly  from 
pain  or  a  sense  of  tension  and  oppression  in  the  head,  or  a  dull, 
aching  feefing  is  experienced  in  the  muscles  of  the  extremities 


1 84  CHRONIC   GASTRITIS. 

or  along  the  course  of  some  important  nerve.  Occasionally 
these  latter  symptoms  are  so  severe  that  the  case  is  regarded 
as  one  of  chronic  rheumatism,  sciatica,  or  neuralgia,  while  the 
gastric  complaint,  which  is  the  cause  of  these  phenomena, 
is  overlooked.  Palpitation  of  the  heart,  epigastric  pulsation 
or  attacks  of  the  so-called  asthma  dyspepticum  are  apt  to  ensue 
after  meals  and  greatly  add  to  the  general  discomfort.  Insom- 
nia is  very  common,  and  when  sleep  is  at  length  attained 
after  hours  of  restlessness,  it  is  usually  disturbed  by  nightmares 
or  sensations  of  unaccountable  panic. 

The  skin  presents  various  indications  of  the  perverted 
general  nutrition.  It  is  usually  dry,  harsh,  sallow,  and  wrinkled, 
while  at  times  an  eczematous,  impetiginous,  or  urticarial 
eruption  makes  its  appearance  without  assignable  cause.  It 
is  interesting  to  notice  that  inflammation  of  the  skin  is  usually 
associated  with  a  marked  diminution  of  the  gastric  symptoms 
(Trousseau,  Fenwick). 

The  hair  tends  to  become  dry  and  prematurely  grey,  and 
usually  falls  out  rapidly  as  soon  as  progressive  emaciation  sets 
in.  The  nails  become  furrowed  and  are  easily  split  and  the 
teeth  often  suffer  from  rapid  caries. 

Coldness  of  the  extremities  is  a  common  cause  of  com- 
plaint and  is  sometimes  attended  by  flushing  of  the  face  and  a 
sense  of  fulness  or  oppression  in  the  head.  In  some  cases 
sHght  shivering  attacks  occur  from  time  to  time  and  the  patients 
are  unduly  susceptible  to  changes  of  temperature.  Chilblains 
are  very  common.  Although  the  temperature  of  the  body  is 
usually  subnormal,  certain  subjects  of  chronic  gastritis  exhibit 
a  slight  febrile  reaction  at  night  from  time  to  time,  accompanied 
by  chilliness  and  a  feehng  of  general  malaise.  During  these 
attacks  there  is  a  marked  exacerbation  of  the  dyspeptic 
symptoms  and  vomiting  is  not  infrequent.  Exposure  to  cold 
or  indulgence  in  alcohol  or  some  indigestible  article  of  food  is 
usually  responsible  for  these  intercurrent  attacks  of  acute  or 
subacute  gastritis. 


PHYSICAL    EXAMINATION.  1 85 

Emaciation  is  almost  always  observed  when  the  disorder 
has  persisted  for  any  length  of  time,  but  it  is  not  an  early 
symptom  unless  the  patient  has  been  previously  out  of  health 
or  the  disease  is  unusually  severe.  More  often  there  is  a 
gradual  but  steady  loss  of  flesh  and  strength,  combined  with 
that  curious  loss  of  energy  which  so  often  betokens  organic 
disease  of  the  stomach. 

Physical  Examination. — During  digestion  the  stomach 
is  frequently  distended  with  gas  and  produces  a  visible  pro- 
trusion of  the  epigastrium.  This  varies  in  degree  at  different 
periods  of  the  day  and  is  always  most  noticeable  in  the  evening. 
On  palpation  the  exposed  portion  of  the  viscus  is  found  to  be 
hypersesthetic,  but  the  localised  tender  area  met  with  in  cases  of 
ulceration  is  absent.  Except  in  those  rare  examples  of  pyloric 
stenosis  due  to  hypertrophy  of  the  mucous  membrane  near  the 
orifice,  the  gastric  walls  present  no  evidence  of  thickening  nor 
can  any  peristaltic  movements  be  observed  after  manipulation. 
A  certain  degree  of  gastrectasis  may  usually  be  detected  after 
the  disease  has  lasted  several  months,  owing  to  the  constant 
stretching  of  the  walls  of  the  organ  by  the  gaseous  products  of 
fermentation  and  perhaps  to  the  extension  of  the  inflammatory 
processes  to  the  muscularis  mucosae,  but  the  great  curvature 
rarely  extends  more  than  i  inch  below  the  level  of  the  navel. 
An  exception  to  this  rule  is  to  be  found,  however,  in  the  gastritis 
of  chronic  phthisis,  where  lardaceous  disease  of  the  tissues  of 
the  stomach  is  often  accompanied  by  great  dilatation  of  the 
organ. 

An  investigation  of  the  secretory  powers  of  the  stomach  is 
always  a  matter  of  great  importance  and  should  be  conducted 
after  the  administration  of  a  test-breakfast.  As  a  rule,  the 
amount  of  material  extracted  by  aspiration  at  the  end  of  an 
hour  is  in  excess  of  the  normal  and  consists  of  a  thick,  slimy 
mass  which  filters  with  difficulty.  It  is  important  to  observe 
that  the  mucus  is  always  intimately  mixed  with  the  food  and 
that  each  coarse  particle  of  bread  is  enveloped  in  a  tenacious 


1 86  CHRONIC   GASTRITIS. 

coating  of  slime.  These  appearances  serve  to  distinguish  the 
mucus  secreted  by  an  inflamed  stomach  from  that  produced 
in  the  nose,  larynx,  or  throat,  which  after  being  swallowed  is 
removed  from  the  stomach  in  the  form  of  isolated  glassy  or 
purulent  balls.  The  fact  that  a  stomach  affected  by  chronic 
inflammation  secretes  an  abundance  of  mucus  can  also  be 
demonstrated  by  washing  out  the  organ  in  the  early  morning, 
when  at  the  end  of  siphonage  a  large  quantity  of  stringy  slime 
will  escape  through  the  tube.  Microscopic  examination  of 
the  mucus  reveals  the  presence  of  numerous  round  cells  and 
various  forms  of  micro-organisms,  mixed  occasionally  with 
casts  of  the  peptic  glands  (Fenwick),  spiral  cells  (Jaworski), 
or  shreds  of  mucous  membrane  (Einhom). 

The  filtered  material  obtained  after  a  test  meal  almost 
always  shows  a  decided  diminution  of  the  gastric  secretion. 
Free  hydrochloric  acid  is  either  absent  altogether  or  only 
exists  in  minute  quantity,  while  the  total  acidity  of  the  fluid 
is  much  less  than  normal  (20-50).  Traces  of  lactic  acid 
may  occur  in  advanced  cases  and  the  volatile  acids  are  usually 
increased.  When  atrophy  of  the  mucous  membrane  takes 
place  the  total  acidity  steadily  diminishes  and  finally  the  acid 
secretion  disappears  altogether.  It  should  never  be  inferred, 
however,  that  a  low  total  acidity  combined  with  an  absence  of 
the  free  acid,  indicates  the  existence  of  atrophy,  since  free 
hydrochloric  acid  often  reappears  after  the  case  has  been  under 
treatment  for  a  short  time,  while  the  total  acidity  of  the  filtrate 
is  always  hable  to  considerable  fluctuations.  It  is  only  after 
repeated  examinations  that  an  accurate  estimate  of  the 
secretory  activity  of  the  stomach  can  be  formed. 

The  pepsin  is  always  reduced  in  severe  cases,  but  it  is  only 
when  extensive  atrophy  has  taken  place  that  the  ferment  fails 
to  be  secreted.  Rennet  is  also  reduced  in  quantity,  but  to  a 
lesser  extent  than  either  the  acid  or  pepsin.  According  to 
Boas,  the  quantitative  estimation  of  the  rennet-zymogen  is  of 
much  clinical  importance,  since  a  marked  diminution  of  the 


COURSE  AND   PROGNOSIS.  187 

ferment  always  indicates  a  severe  and  intractable  form  of 
gastritis.  The  easiest  method  is  to  introduce  into  the  stomach 
a  graduated  solution  of  hydrochloric  acid,  and,  after  allowing 
it  to  remain  in  the  organ  for  a  certain  time,  to  remove  it  by 
aspiration  and  to  determine  the  amount  of  the  enzyme  in  the 
fluid  in  the  usual  way. 

Motor  insufficiency  is  usually  supposed  to  be  the  cause  of 
the  tardy  digestion  of  food  in  cases  of  gastritis,  but  this  sup- 
position is  often  erroneous.  In  most  instances  the  presence  of 
undigested  masses  of  food  in  the  stomach  several  hours  after 
their  ingestion  is  due  to  the  diminished  activity  of  the  gastric 
J.  secretion,  while  the  excess  of  mucus  constitutes  an  almost^ 
1  impenetrable  barrier  to  the  proper  incorporation  of  ingesta  i 
\jfvith  the  digestive  fluid.  On  the  other  hand,  it  is  probable 
that  in  many  cases  of  chronic  gastritis  this  tendency  to  food 
stagnation  is  to  a  great  extent  counteracted  by  an  increased 
peristalsis  of  the  stomach,  whereby  its  undigested  contents  are 
hurried  into  the  intestine  and  submitted  to  digestive  processes 
of  a  more  active  character  than  those  existent  in  the  inflamed 
stomach.  This  fact  is  easily  proved  by  noting  the  rapidity 
with  which  milk  and  other  fluids  escape  from  the  stomach  into 
the  bowel,  while  solid  articles  of  diet  remain  stagnant  for 
many  hours.  At  a  late  stage  of  the  disease  the  motor  power 
invariably  fails  and  the  organ  shows  signs  of  dilatation. 

Course  and  Prognosis. — The  disease  always  pursues  a 
chronic  course,  and  in  some  instances  several  years  may  elapse 
before  the  general  nutrition  shows  signs  of  serious  failure.  As 
a  rule,  the  course  of  the  primary  complaint  is  marked  by  many 
remissions  and  exacerbation,  which  depend  for  the  most  part 
upon  the  varied  activity  of  its  exciting  cause.  This  is  partic- 
ularly the  case  in  the  gastritis  of  alcoholism,  which  may 
apparently  subside  for  months  when  the  habit  is  given  up, 
to  break  out  with  renewed  severity  when  the  patient  once 
more  indulges  his  drinking  propensities. 

The  two   great  local  factors  which  prevent  the  cure  of 


1 88  CHRONIC   GASTRITIS. 

gastric  inflammation,  even  when  the  exciting  cause  has  been 
removed,  are  embarrassment  of  the  circulation  and  impairment 
of  the  motor  power  of  the  viscus.  The  former  usually  arises 
from  coexisting  cirrhosis  of  the  liver,  the  gradual  contraction 
of  which  causes  an  ever-increasing  obstruction  to  the  circu- 
lation of  blood  through  the  portal  vein  and  engorgement  of 
the  venous  system  of  the  stomach.  Motor  insufiiciency  occurs 
at  a  late  stage  of  the  primary  complaint  and  is  due  to  excessive 
stretching  of  the  musculature  of  the  organ  combined  possibly 
with  the  spread  of  the  inflammation  into  the  middle  coat. 
When  this  complication  develops,  fermentation  of  the  food 
becomes  a  prominent  symptom,  the  compensatory  digestive 
activity  of  the  intestines  is  destroyed,  and  the  failure  of  ab- 
sorption leads  to  a  rapid  deterioration  of  the  health. 

Secondary  chronic  gastritis  being  almost  always  a  sequela 
of  organic  disease  of  some  important  organ  of  the  body  rarely 
undergoes  spontaneous  cure,  and  by  seriously  interfering 
with  the  general  nutrition,  materially  hastens  the  fatal  termin- 
ation of  the  original  complaint. 

Diagnosis.  —To  judge  from  the  frequency  and  readiness  with 
which  the  majority  of  practitioners  are  wont  to  diagnose  "  chronic 
gastritis,"  it  might  easily  be  imagined  that  the  recognition  of 
the  disease  presented  few  difflculties  and  that  its  existence 
was  a  matter  of  little  importance.  But  even  the  most  casual 
consideration  of  its  etiology  is  sufficient  to  show  that,  whereas 
the  primary  form  is  almost  invariably  due  to  serious  toxic 
poisoning,  the  secondary  and  more  common  variety  bespeaks 
an  incurable  organic  disease  either  of  the  stomach  itself  or  of 
some  other  vital  organ  of  the  body.  Moreover,  it  is  generally 
conceded  by  experts  that  the  symptoms  and  physical  signs 
that  accompany  chronic  inflammation  of  the  stomach  are  in 
no  way  pathognomonic  and  that  several  examinations  of  the 
gastric  secretion  have  to  be  made  before  any  definite  con- 
clusions can  be  drawn  from  them.  It  is  obvious,  therefore, 
that   while   the   diagnosis   of  chronic   gastritis   must   always 


DIAGNOSIS.  189 

entail  much  careful  consideration,  a  complete  examination 
of  all  the  organs  of  the  body  has  to  be  made  before  the  cause 
of  the  disease  can  be  ascertained  and  a  prognosis  formulated. 

The  existence  of  chronic  gastritis  may  be  inferred  from 
the  following  symptoms  and  physical  signs:  (i)  Discomfort 
and  distention  occurring  within  an  hour  or  two  after  a  meal 
consisting  of  meat  or  other  solid  material.  (2)  Eructations  of 
gas  and  occasional  pyrosis  during  the  period  of  gastric  digestion. 
(3)  Vomiting  of  glairy  mucus  in  the  early  morning,  preceded 
by  severe  nausea  and  retching.  (4)  Occasional  vomiting 
after  meals,  the  constituents  of  which  are  enveloped  in  mucus 
and  present  little  or  no  signs  of  digestion,  (5)  Mental  depres- 
sion and  other  nervous  phenomena  out  of  all  proportion  to  the 
apparent  failure  of  digestion  and  absorption.  (6)  After  a 
meal  the  stomach  is  found  to  be  distended  with  gas,  and  in 
old-standing  cases  a  moderate  degree  of  gastrectasis  is  often 
present.  (7)  As  the  result  of  several  test-meals,  the  particles 
of  bread  are  found  to  be  undigested  and  to  be  enveloped  in  a 
thick  coating  of  slimy  mucus;  free  hydrochloric  acid  is  absent, 
the  total  acidity  of  the  chyme  is  much  diminished,  and  the 
secretion  of  both  pepsin  and  rennet  may  be  deficient. 

The  principal  complaints  from  which  primary  chronic 
gastritis  has  to  be  distinguished  are  carcinoma,  myasthenia, 
and  neurasthenia  of  the  stomach. 

Cancer  of  the  stomach  is  very  prone  to  be  accompanied 
by  chronic  inflammation  of  the  gastric  mucosa  from  an  early 
period  of  its  development,  and  it  may  not  be  until  the  occur- 
rence of  certain  special  symptoms  that  the  secondary  nature 
of  the  gastritis  becomes  apparent.  It  is,  therefore,  wise  to 
regard  with  suspicion  every  case  or  chronic  gastritis  occurring 
after  middle  life  until  its  cause  can  definitely  be  determined^ 
Both  carcinoma  and  chronic  gastritis  commence  in  an  in- 
sidious manner,  but  the  course  of  the  former  disease  is  rela- 
tively rapid  and  severe  general  and  local  symptoms  usually 
develop  long  before  a  simple  gastritis  would  have  had  time  to 


igo  CHRONIC   GASTRITIS. 

affect  the  general  nutrition  to  a  like  degree.  Thus,  loss  of 
energy  and  strength  are  early  phenomena  of  the  morbid 
growth  and  emaciation  and  ansemia  proceed  unchecked 
throughout  the  whole  course  of  the  complaint.  Pain  during 
digestion  is  a  constant  feature  of  cancer  of  the  body  of  the 
stomach;  and  even  when  the  pylorus  is  primarily  affected, 
this  symptom  usually  makes  its  appearance  owing  to  ulceration 
of  the  growth.  Early  morning  vomiting  is  rare  in  cases  of 
cancer,  but  emesis  at  other  times  of  the  day  or  when  the 
patient  retires  to  bed  at  night  is  a  symptom  that  increases  in 
frequency  as  the  disease  progresses.  Haemorrhage  is  met 
with  in  both,  but  in  chronic  gastritis  cirrhosis  of  the  liver  is 
almost  invariably  present  when  the  haematemesis  is  copious, 
while  in  carcinoma  the  bleeding  is  often  slight,  but  recurs  at 
short  intervals,  and  a  tube  will  frequently  evacuate  altered 
blood  from  the  stomach. 

A  considerable  degree  of  gastrectasis,  especially  if  associated 
with  visible  peristalsis,  is  always  suggestive  of  pyloric  stenosis, 
while  the  discovery  of  a  tumour  connected  with  the  stomach, 
of  enlargement  of  the  liver  or  of  nodules  in  the  abdominal 
wall  will  at  once  raise  a  suspicion  of  malignant  disease. 
After  a  test-meal,  the  material  removed  from  a  stomach 
affected  by  carcinoma  presents  a  remarkably  low  total  acidity, 
free  hydrochloric  acid  is  usually  absent,  and  the  fluid  often 
contains  lactic  acid.  The  motility  of  the  organ  is  also  im- 
paired from  an  early  stage  of  the  complaint. 

Primary  myasthenia  differs  from  chronic  gastritis  in  several 
important  particulars.  As  the  complaint  is  essentially  an 
enfeeblement  of  the  muscular  coat  of  the  organ,  the  most 
noticeable  phenomena  are  stagnation  and  fermentation  of  the 
food.  Nausea  and  vomiting  are  never  met  with  in  uncom- 
plicated cases,  pyrosis  is  rare,  and  the  characteristic  vomiting 
of  mucus  in  the  early  morning  is  absent.  Exploration  of  the 
stomach  after  a  test  meal  shows  but  slight  diminution  of  its 
secretory  powers  and  an  absence  of  that  glairy  mucus  which 


TREATMENT.  I91 

is  pathognomonic  of  chronic  inflammation;  the  ferments 
present  no  signs  of  diminution,  but  food  is  retained  in  the 
enfeebled  organ  for  a  considerable  time.  The  exciting  causes 
of  chronic  gastritis  are  also  absent. 

Neurasthenia  gastrica  ought  not  be  confounded  with 
chronic  gastritis.  The  wayward  nature  of  its  symptoms  and 
the  irregular  course  of  the  disorder  should  at  once  indicate  the 
nervous  origin  of  the  complaint,  while  the  absence  of  vomiting 
in  the  early  morning,  the  rapidity  with  which  the  stomach 
empties  itself  after  a  test-meal,  and  the  normal  features 
presented  by  the  chyme  are  sufficient  to  negative  the  suggestion 
of  gastritis. 

Treatment. — (i)  General. — The  various  conditions  which 
tend  to  excite  or  to  perpetuate  inflammation  of  the  stomach 
must  be  carefully  avoided,  and  such  adverse  influences  as 
exposure  to  extremes  of  temperature,  insufficient  mastication 
of  the  food,  abuse  of  alcohol  or  tobacco,  or  constant  indulgence 
in  rich  or  indigestible  articles  of  food  must  be  guarded  against. 
Special  attention  must  also  be  paid  to  the  condition  of  those 
organs  of  the  body  whose  functional  derangement  is  particularly 
apt  to  excite  gastritis,  and  the  treatment  appropriate  to 
diseases  of  the  lungs,  heart,  liver,  kidneys,  or  of  the  blood  should 
be  adopted  as  occasion  requires.  In  all  cases  the  patient 
should  endeavour  to  lead  a  rational  existence  and  indulge  in 
some  regular  form  of  exercise  which  does  not  entail  either 
overexertion  or  excessive  fatigue.  Walking,  golf,  and  horse 
riding  are  usually  beneficial,  and  in  many  instances  a  cold 
or  tepid  sponge  bath  on  rising  followed  by  some  form  of 
calisthenic  exercise  for  about  ten  minutes  is  a  useful  adjunct 
to  the  other  methods  of  treatment. 

Lavage,  or  washing  out  the  stomach,  is  indicated  in  all 
chronic  cases  where  there  is  either  an  excessive  secretion  of 
mucus  or  stagnation  with  fermentation  of  the  food.  In  the 
former  case  the  operation  is  most  advantageous  when  per- 
formed in  the  early  morning,  and  sufficient  water  should  be 


192  CHROMIC   GASTRITIS. 

used  to  ensure  the  complete  evacuation  of  the  mucus;  and 
since  the  tenacious  shme  is  difi&cult  to  evacuate,  it  is  advisable 
to  make  the  patient  at  first  sit  upright,  then  lie  upon  his  back 
and  finally  recline  upon  his  left  side  so  as  to  ensure  a  complete 
washing  of  the  entire  surface  of  the  stomach.  Gentle  massage 
of  the  organ  during  the  procedure  often  aids  the  expulsion  of 
the  mucus;  while  the  addition  of  bicarbonate  of  sodium  to 
the  water,  in  the  proportion  of  a  teaspoonful  to  the  quart, 
renders  the  secretion  more  easy  of  removal.  When  lavage  is 
undertaken  on  account  of  fermentation  of  stagnant  food,  it 
may  be  performed  either  in  the  early  morning  or  three  hours 
after  a  light  evening  meal.  The  food  is  first  evacuated,  and 
the  stomach  is  then  thoroughly  washed  out  with  a  mild 
antiseptic  solution,  such  as  salicylic  acid  (1:1,000),  potassium 
permanganate  (0.05:1,000),  resorcin,  (4:1,000),  thymol 
(0.5:1,000),  benzol  (5:1,000),  or  a  dilute  solution  of  hydro- 
chloric acid  (o .  5-2  :i,ooo).  If  vomiting  is  a  feature  of  the  case, 
lavage  should  be  performed  both  morning  and  evening  for 
the  first  ten  days.  After  the  expiration  of  three  weeks  or  a 
month,  every  alternate  day  is  usually  sufficient,  and  if  the  case 
continues  to  make  satisfactory  improvement,  it  is  afterwards 
gradually  discontinued.  In  the  majority  of  the  cases  the 
good  effects  of  washing  out  the  stomach  become  apparent 
about  the  third  day  of  the  treatment,  when  the  patient  ex- 
periences an  increase  of  appetite  and  a  marked  diminution  of 
the  nausea,  distention,  and  other  symptoms  of  the  complaint. 
When  lavage  is  discontinued,  a  douche  may  often  be 
employed  with  great  advantage,  since  the  forcible  spraying 
of  the  gastric  mucosa  appears  both  to  stimulate  secretion  and 
also  to  increase  the  tone  of  the  muscular  coat  of  the  organ. 
For  this  purpose  a  soft  tube,  provided  with  numerous  small 
holes  at  its  lower  end  should  be  used,  and  the  water  injected 
under  pressure  by  raising  the  funnel  or  reservoir  above  the 
level  of  the  patient's  head.  Einhorn  advocates  an  ordinary 
spray  apparatus  to  the  hard-rubber  branch  of  which  a  soft 


TREATMENT.  1 93 

stomach-tube  is  attached.  Within  the  latter  is  another  soft 
tube  of  small  calibre  which  conveys  the  fluid  from  the  bottle 
to  a  vulcanite  nozzle.  By  this  means  the  entire  surface  of  the 
stomach  can  be  subjected  to  a  fine  spray.  When  the  coats 
of  the  viscus  require  tone,  water  at  a  temperature  of  65°  F. 
is  employed,  but  if  the  gastric  secretion  is  also  deficient,  the 
addition  of  chloride  of  sodium  (90  grains  to  the  pint)  is 
found  to  increase  the  production  of  hydrochloric  acid  (Rosen- 
heim), while  nitrate  of  silver  (1:1,000)  exerts  a  contrary  effect. 
Chloroform  water  added  to  the  douche  acts  as  a  powerful  local 
sedative,  and  Fleiner  states  that  a  douche  of  infusion  of  hops 
or  quassia  is  a  wonderful  stimulant  of  the  appetite.  In  all 
cases  where  a  medicated  solution  is  employed  the  fluid  should 
not  remain  in  the  stomach  for  more  than  a  minute  and  the 
viscus  should  subsequently  be  washed  out  with  warm  water. 
No  food  should  be  present  when  a  douche  is  employed. 

Electricity  is  only  of  value  in  long-standing  cases  of  gastritis 
where  the  muscular  coat  is  markedly  atonic  and  secondary 
myasthenia  has  given  rise  to  retention  of  food.  In  such  cases 
regular  massage  of  the  stomach  combined  with  hydrothera- 
peutic  measures  may  also  be  employed. 

Diet. — It  is  impossible  to  formulate  a  definite  scheme  of 
diet  applicable  to  all  cases  of  chronic  gastritis,  since  the  power 
of  digestion  and  assimilation  vary  greatly  in  different  cases  as 
well  as  at  different  stages  of  the  same  case.  The  main  object 
to  be  kept  in  view  is  to  prescribe  food  of  a  quality  and  in  such 
quantity  that  the  enfeebled  secretory  and  motor  powers  of  the 
stomach  are  in  no  way  overtaxed.  When  a  case  first  comes 
under  treatment,  and  especially  if  it  is  suffering  from  any  acute 
manifestations  of  the  disease,  rest  in  bed  for  ten  days  or  a 
fortnight  and  the  administration  of  some  bland  form  of 
nourishment  afford  immediate  relief  to  the  pain  and  vomiting, 
check  the  emaciation,  and  promote  restful  sleep.  As  a  rule,  the 
food  should  be  administered  every  three  hours,  and  the  fluid 
be  restricted  to  half  a  pint  on  each  occasion.  If  milk  agrees, 
13 


194  CHRONIC   GASTRITIS. 

from  3  to  4  pints  may  be  given  in  the  twenty-four  hours, 
but  if  it  gives  rise  to  discomfort  it  should  be  diluted  with  lime- 
water,  sterilised,  or  peptonised. 

In  many  cases  sour  milk  prepared  in  the  manner  recom- 
mended by  Metchnikoff  with  lactobacilline  is  a  most  excellent 
adjunct  to  the  dietetic  treatment,  but  ten  days  usually  elapse 
before  its  good  effects  become  apparent.  Half  a  pint  of  the 
sour  curds,  well  sprinkled  with  sugar,  may  be  taken  twice  in 
the  day.  Eggs,  either  poached  or  lightly  boiled,  strong  clear 
soups,  meat  essences  and  jelhes,  junket,  custard,  cocoa  made 
with  milk,  milk  puddings,  Benger's  food,  revalenta  aracaib, 
Gerrard's  peptones,  with  toast,  rusks,  and  butter  should  con- 
stitute the  remainder  of  the  dietary. 

It  is  often  stated  that  proteid  foods  should  be  withheld 
whenever  the  gastric  secretion  is  deficient,  but  in  cases  of 
chronic  gastritis  the  motor  power  of  the  stomach  is  rarely 
impaired  until  the  terminal  stage  of  the  disease,  and  any 
diminution  of  proteid  digestion  in  the  stomach  is  amply  com- 
pensated by  an  increased  activity  of  the  biliary  and  pancreatic 
secretions.  Carbohydrates  may  also  be  freely  given,  but 
vegetables  that  contain  a  large  amount  of  cellulose  and  all 
raw  fruits  must  be  excluded  from  the  dietary.  Fats  are 
extremely  valuable,  especially  when  the  general  nutrition  has 
been  much  reduced,  and  for  this  purpose  the  patient  should  be 
encouraged  to  take  plenty  of  cream,  butter,  or  dripping  with 
his  meals. 

After  the  lapse  of  a  fortnight,  he  is  usually  able  to  leave 
his  bed  and  to  attempt  a  more  extended  dietary.  If  the 
milk  and  other  fluids  agree  they  may  still  be  continued  in 
lesser  quantity,  and  the  sour  milk  be  taken  once  or  twice  a  day. 
The  most  digestible  articles  of  food  at  this  period  of  the 
complaint  are  as  follows:  Calf's  brains  and  thymus,  boiled 
cod,  whiting,  and  plaice,  oysters,  scraped  raw  beef,  tripe, 
sweetbreads,  mashed  potato,  cauliflower,  asparagus,  toast, 
rusks,  oatmeal,  tapioca,  sago,  cornflower,  and  rice,  to  which 


TREATMENT.  1 95 

may  shortly  be  added  boiled  chicken,  partridge,  or  pigeon, 
well-stewed  beef,  boiled  ham,  calf's  feet,  sardines,  spinach,  and 
stewed  apple.  If  the  case  continues  to  progress  in  a  satis- 
factory manner,  the  diet  is  further  enlarged  at  the  end  of 
another  month  by  the  inclusion  of  such  articles  as  turkey, 
game  of  various  kinds,  underdone  roast  mutton  or  sirloin  of 
beef,  lightly  grilled  chops  or  steaks,  and  plain  puddings.  On 
the  other  hand,  hard  or  coarse-fibred  meats,  pork,  veal,  sausages, 
lobster,  salmon,  mackerel,  carrots,  salads,  celery,  cabbage, 
cucumber,  pickles,  cheese,  new  bread,  uncooked  fruits,  and 
alcoholic  drinks  should  be  prohibited  until  the  health  has  been 
completely  restored. 

Medicinal. — Natural  mineral  waters  have  always  been  held 
in  great  repute  for  the  treatment  of  chronic  inflammation  of  the 
stomach,  and  there  can  be  no  doubt  that  in  many  cases  much 
relief  is  obtained  by  a  few  weeks'  treatment  at  a  suitable 
watering-place.  Although  there  is  little  accurate  knowledge 
concerning  the  mode  of  action  of  the  various  waters  upon  the 
digestive  system,  it  is  probable  that  they  act  much  in  the  same 
way  as  systematic  lavage,  in  that  they  wash  the  contents  of  the 
stomach  into  the  intestine,  aid  the  solution  of  mucus,  and 
stimulate  the  gastric  glands.  It  must  also  be  added,  that  many 
patients  will  cheerfully  submit  to  a  strict  regime  and  a  thorough 
course  of  treatment  at  a  spa  or  continental  sanatorium,  when 
no  amount  of  persuasion  will  induce  them  to  follow  the  same 
principles  in  their  own  homes,  and  it  is  consequently  often  a 
matter  of  expediency  rather  than  of  absolute  necessity  that  a 
course  of  mineral  waters  is  recommended  in  place  of  the  usual 
medicinal  treatment.  But  before  such  advice  is  given  care 
must  be  taken  that  the  general  health  is  sufficiently  good  to 
withstand  the  exertion  and  excitement  of  a  long  journey,  and 
the  somewhat  debilitating  effects  of  the  mineral  waters.  In 
this  connection  it  is  well  to  bear  in  mind  that  chronic  gastritis 
is  very  often  merely  an  expression  of  serious  organic  disease 
of  some  vital  organ  of  the  body,  and  that  an  attempt  to  submit 


196  CHRONIC   GASTRITIS. 

a  person  suffering  from  a  fatal  affection  of  the  heart,  lungs, 
stomach,  or  kidneys  to  the  orthodox  treatment  at  a  foreign 
watering-place,  merely  because  chronic  gastritis  happens  to 
complicate  the  original  disorder,  is  wholly  unscientific  and 
frequently  ends  in  disaster.  The  somewhat  sinister  reputation 
of  Carlsbad  as  a  "kill  or  cure"  treatment  is  almost  entirely 
due  to  the  reckless  manner  in  which  medical  men  send  se- 
rious and  unsuitable  cases  thither  to  undergo  a  course  of 
depletive  treatment. 

Alkaline  waters  are  chiefly  indicated  in  cases  of  secondary 
gastritis,  where  the  heart,  kidneys,  or  some  other  important 
organ  of  the  body  is  seriously  affected  and  much  irritability 
of  the  stomach  exists.  The  warm  springs  of  Vichy  are  partic- 
ularly valuable  under  these  conditions,  but  if  a  somewhat 
milder  treatment  is  required,  the  warm  waters  of  Neuenahr 
may  be  preferred.  The  salt  waters  of  Kissingen,  Homburg, 
and  Wiesbaden  exert  a  marked  effect  upon  gastric  subacidity 
and  are  chiefly  indicated  during  the  convalescent  stage  of 
primary  chronic  gastritis  and  in  that  variety  which  ensues  from 
long-standing  myasthenia.  The  effect  of  the  saline  is  to 
promote  the  secretion  of  gastric  juice,  to  tone  up  the  mucous 
membrane,  and  to  greatly  improve  the  general  health  (Dapper). 
In  England,  Harrogate  and  Llandrindod  possess  somewhat 
similar  waters  and  have  the  advantage  of  a  far  more  bracing 
climate. 

The  springs  that  contain  sulphate  of  sodium  in  addition  to 
the  chloride  and  bicarbonate  are  chiefly  of  use  in  that  form  of 
chronic  gastritis  which  owes  its  origin  to  diseases  of  the  liver, 
gall-bladder,  and  pancreas,  to  habitual  overindulgence  in  rich 
living  or  to  the  abuse  of  alcohol.  The  best  waters  of  this 
kind  are  those  of  Carlsbad,  Marienbad,  Tarasp,  and  Brides-les 
Bains.  In  all  cases  the  water  should  possess  a  medium  tem- 
perature, as  the  inflamed  stomach  is  intolerant  of  cold  or 
unduly  hot  fluids. 

The  indications  for  the  administration  of  drugs  are  three 


TREATMENT.  I97 

in  number:  (i)  to  allay  the  symptoms  of  gastric  irritation  and 
inhibit  fermentation;  (2)  to  stimulate  the  appetite;  (3)  to 
correct  constipation. 

(i)  The  abdominal  discomfort,  distention,  nausea,  and 
other  symptoms  of  chronic  gastritis  are  partly  due  to  dimin- 
ished secretion  and  partly  to  direct  irritation  of  the  mucous 
membrane  of  the  stomach.  Both  these  abnormal  conditions 
subside  to  a  great  extent  under  daily  lavage  and  careful  dieting, 
but  they  rarely  disappear  completely  without  the  administration 
of  drugs.  The  carbonate  of  bismuth  is  pre-eminently  valuable 
in  these  cases,  and  may  advantageously  be  combined  with 
bicarbonate  of  sodium  (15  grains  of  each)  and  from  8  to  12 
minims  of  the  glycerin  of  carbolic  acid.  The  further  addition 
of  a  drachm  of  pure  glycerin  to  the  mixture  increases  its  anti- 
septic properties  and  also  appears  to  stimulate  the  gastric  se- 
cretion. The  medicine  is  given  between  the  meals,  and  should 
nausea  be  a  troublesome  feature,  a  few  drops  of  dilute  hydro- 
cyanic acid  may  be  added  to  it  with  benefit.  In  less  severe 
cases  the  solution  of  bismuth  may  be  prescribed  in  a  similar 
combination.  A  preparation  of  morphine  is  only  necessary 
when  acute  gastritis  accompanied  by  excessive  vomiting  com- 
plicates the  chronic  complaint,  and  is  contraindicated  by  the 
presence  of  albumin  in  the  urine.  In  gastritis  of  alcoholic  origin 
15  grains  of  chloretone  in  capsules  or  a  drachm  of  the  ehxir  in 
an  alkaline  mixture  is  often  attended  by  very  satisfactory  results. 
Some  authorities  speak  highly  of  salicylate  of  sodium  as  an 
antiseptic,  while  others  prefer  the  capsules  of  salicylic  acid, 
but,  according  to  my  experience,  they  are  much  inferior  to 
carbolic  acid.  A  drachm  of  the  solution  of  perchloride  of 
mercury  administered  three  times  a  day  after  meals  for  two 
months  is  an  excellent  antiseptic  when  the  gastritis  is  accom- 
panied by  alcoholic  cirrhosis  of  the  liver.  If  acidity  is  the  chief 
cause  of  complaint,  the  compound  lozenges  of  bismuth  or  cap- 
sules containing  calcined  magnesia  and  bicarbonate  of  sodium 
taken  an  hour  after  food  rarely  fail  to  relieve  the  symptom. 


ig8  CHRONIC    GASTRITIS. 

(2)  The  best  stimulant  to  the  appetite  is  afforded  by  the 
systematic  removal  of  the  mucus  by  lavage;  but  when  this 
procedure  cannot  be  carried  out,  recourse  must  be  had  to  such 
drugs  as  are  supposed  to  excite  a  desire  for  food.  In  many 
instances  a  cupful  of  beef  tea  or  of  hot  water  taken  a  quarter 
of  an  hour  before  a  meal  excites  a  certain  amount  of  relish 
for  the  food,  or  15  minims  of  dilute  hydrochloric  acid  in  2  oz. 
of  water  may  be  taken  half  an  hour  before  food  with  good 
effect.  Condurango  has  long  enjoyed  a  considerable  repu- 
tation as  a  stomachic,  and  a  teaspoonful  of  the  wine  or  30 
minims  of  the  liquid  extract  may  be  prescribed  before  each 
meal,  either  with  or  without  hydrochloric  acid. 

Orexin  is  usually  too  irritating  to  be  borne  by  an  inflamed 
stomach,  while  nux  vomica,  iron,  quinine,  and  the  various 
so-called  gastric  elixirs  almost  always  increase  the  inflammatory 
mischief.  The  fact  that  a  deficiency  of  the  mineral  acid  is 
always  accompanied  by  a  diminution  of  the  peptic  ferment  has 
led  to  the  introduction  of  pepsin,  papain,  papayotin,  and  the 
pancreatic  preparations  as  artificial  aids  to  digestion.  Per- 
sonally, I  have  never  observed  the  slightest  good  arise  from  the 
administration  of  these  various  digestives  in  cases  of  chronic 
gastritis,  and  even  takadiastase,  which  theoretically  might 
be  of  value,  is  quite  useless.  In  this  respect  my  experience 
seems  to  tally  with  that  of  Riegel,  Grote,  and  other  clinicians 
who  have  investigated  the  matter  from  a  practical  stand-point. 

(3)  In  every  case  of  alcoholic  gastritis,  as  well  as  in  many 
of  the  secondary  forms  of  the  complaint,  the  administration 
of  a  saline  each  morning  before  breakfast  is  of  the  greatest 
value.  As  a  rule,  a  mixture  in  equal  proportions  of  the 
phosphate  and  dried  sulphate  of  sodium  answers  best,  but 
artificial  Carlsbad  salts,  Kutnow's  powder,  sulphate  and  car- 
bonate of  magnesia,  or  the  Rochelle  salt  may  be  prescribed  or 
the  natural  waters  of  Carlsbad  or  Marienbad  may  be  given  in- 
stead. Enough  should  be  taken  to  procure  two  liquid  motions 
each  day,  and  after  a  few  weeks  the  dose  may  gradually  be 


PATHOLOGY.  199 

diminished.     The  natural  aperient  waters,  such  as  Apenta, 
Hunyadi  Janos,  are  of  less  value. 

(3)  ATROPHY  OF  THE  MUCOUS  MEMBRANE  OF  THE  STOMACH. 

(Synonyms — Atrophic  Gastritis;  Phthisis  Ventriculi; 

Anadeny  of  the  Stomach.) 
Under  certain  circumstances  chronic  inflammation  of  the 
stomach  leads  to  fibrosis  of  the  gastric  mucosa  and  complete 
atrophy  of  its  secretory  structures.  This  lesion  resembles  in 
its  clinical  features  the  nervous  variety  of  achylia  gastrica, 
but  inasmuch  as  the  suppression  of  the  functions  of  the  stomach 
depends  upon  an  organic  lesion,  it  is  important  that  the  two 
complaints  should  be  carefully  distinguished  from  one  another. 
Pathology. — The  appearances  presented  by  the  stomach 
vary  in  different  cases.  In  most  instances  the  organ  is  some- 
what dilated  and  dislocated  downward,  while  its  walls  are 
abnormally  thin  and  transparent.  Less  frequently  it  exhibits 
no  obvious  signs  of  disease,  or  it  may  even  be  smaller  and 
thicker  than  in  a  healthy  state.  Neither  postmortem  digestion 
nor  ulceration  is  ever  encountered  and  there  is  no  hyper- 
trophic stenosis  of  the  pylorus.  The  inner  surface  of  the 
organ  has  a  peculiar  smooth  and  glistening  appearance,  and 
there  is  a  total  absence  of  rugae. 

Microscopical  examination  shows  that  atrophy  of  the  gastric 
mucosa  may  be  of  two  kinds.  In  one  the  inflammatory 
trouble  is  restricted  to  the  peptic  glands,  while  in  the  other 
the  destruction  of  these  structures  is  merely  a  result  of  a 
general  cirrhosis  of  the  mucous  membrane.  In  the  former 
case  the  connective  tissue  elements  are  only  shghtly  increased 
and  the  glands  appear  like  shrunken,  wrinkled  sacs  that  at 
most  contain  a  few  detached  and  degenerated  cells.  The 
mouths  of  the  ducts  are  dilated,  and  the  surface  of  the  mucosa 
exhibits  here  and  there  a  few  goblet  cells.  The  morbid 
changes  are  chiefly  confined  to  the  inner  coat  of  the  stomach, 
but  the  submucous  and  muscular  tunics  may  also  show  signs 


200    ATROPHY   OF   THE   MUCOUS    MEMBRANE   OF   THE   STOMACH. 

of  atrophy.  Chronic  interstitial  gastritis,  or  cirrhosis,  is  by 
far  the  most  frequent  cause  of  glandular  atrophy.  In  these 
cases  the  mucous  membrane  is  quite  devoid  of  columnar 
epithelium,  and  often  presents  a  peculiar  villous  or  papillary 
appearance  owing  to  the  accumulation  of  the  organised 
products  of  inflammation  between  the  mouths  of  the  ducts. 
The  interglandular  connective  tissue  is  greatly  increased, 
and  its  contraction  causes  compression  and  destruction 
of  the  tubules,  remnants  of  which,  in  the  form  of  small 
cysts,  may  be  visible  in  the  cirrhotic  tissue.  The  new  fibrous 
elements  are  highly  vascular  and  contain  numerous  blood 
vessels  of  recent  formation.  When  the  inflammation  has 
spread  into  the  deeper  structures,  the  muscularis  mucosae  is 
often  completely  destroyed,  the  submucous  tissue  is  thickened 
and  condensed,  and  the  small  arterioles  that  pass  obliquely 
upward  to  supply  the  mucous  membrane  exhibit  sclerotic 
changes  in  their  inner  and  middle  coats  and  are  sometimes 
filled  with  thrombi.  The  muscular  tunic  is  intersected  by 
bands  of  fibrous  tissue,  and  its  constituent  fibres  appear 
granular  and  fatty.  Fatty  degeneration  of  the  nervous 
plexuses  of  Meissner  and  Auerbach  have  been  observed  in 
some  instances  (Jiirgens,  Blaschko,  Sasaki)  and  changes  in 
the  spinal  cord  have  also  been  detected  (Eisenlohr).  Although 
the  disease  usually  involves  the  whole  stomach,  it  is  always 
most  advanced  in  the  pyloric  region  and  in  the  neighbourhood 
of  the  lesser  curvature,  while  in  some  cases  isolated  patches 
of  atrophy  are  scattered  over  the  greater  part  of  the  viscus. 
As  a  rule,  the  duodenum  and  colon  suffer  in  a  similar 
manner. 

Etiology. — Samuel  Fenwick  was  the  first  to  call  attention 
to  the  existence  of  atrophy  of  the  stomach  in  pernicious 
anaemia  and  in  certain  cases  of  carcinoma  affecting  the  breast, 
intestine,  and  uterus.  Since  the  publication  of  these  researches 
in  1879  the  subject  has  attracted  considerable  attention,  and  it 
is  now  believed  that  while  atrophy  of  the  gastric  mucosa  may 


ETIOLOGY.  20I 

occasionally  occur  as  a  primary  disease,  in  the  vast  majority 
of  cases  it  is  the  result  of  a  chronic  gastritis  of  local  or  toxaemic 
origin. 

(i)  Many  organic  diseases  of  the  stomach  are  accompanied 
by  inflammation  that  spreads  in  a  centrifugal  manner  from 
the  affected  spot  and  is  followed  by  destruction  of  the  peptic 
glands.  In  cases  of  simple  ulcer  the  mischief  is  limited  to  the 
immediate  vicinity  of  the  sore,  but  in  the  syphilitic  and  tuber- 
cular varieties  the  atrophy  may  affect  a  comparatively  large 
area  of  the  mucosa,  owing  to  the  vascular  changes  that  occur  in 
these  diseases.  Carcinoma  is  invariably  accompanied  by  a 
severe  and  widely  diffused  form  of  atrophic  gastritis,  and  it  is 
probably  for  this  reason  that  free  hydrochloric  acid  usually 
disappears  at  an  early  stage  of  the  complaint  and  lactic  acid 
fermentation  becomes  so  conspicuous.  In  this  connection 
it  is  interesting  to  observe  that  the  severity  of  the  gastritis 
seems  to  depend  rather  upon  the  condition  of  the  neoplasm 
than  upon  its  size,  since  it  is  foimd  that  a  small  growth  that  has 
undergone  ulceration,  especially  if  situated  in  the  cardiac 
region  of  the  organ,  is  attended  by  more  destructive  inflam- 
mation than  one  of  much  greater  magnitude  whose  surface 
remains  intact.  In  like  manner  carcinomata  of  the  breast, 
uterus,  and  intestine  are  chiefly  accompanied  by  gastritis  when 
they  exhibit  a  comparatively  slow  growth  and  are  accompanied 
by  profound  cachexia.  From  these  facts  it  would  appear 
that  the  secondary  inflammation  and  atrophy  of  the  gastro- 
intestinal mucous  membrane  met  with  in  cancer  are  due  to  the 
absorption  of  a  chemical  poison  produced  by  disintegration 
of  the  morbid  growth. 

(2)  Chronic  gastritis  leading  to  atrophy  is  frequently 
encountered  in  cases  of  chronic  phthisis,  bronchiectasis,  cysto- 
pyelitis,  and  interstitial  nephritis.  As  it  occurs  independently 
of  amyloid  degeneration,  it  is  probably  caused  by  the  general 
toxaemia  that  ensues  from  these  diseases.  Atrophic  gastritis 
is  also  occasionally  met  with  in  diabetes  (Rosenstein). 


202    ATROPHY   OF   THE   MUCOUS   MEMBRANE    OF   THE    STOMACH. 

(3)  Conditions  which  obstruct  the  portal  circulation  and 
thus  produce  venous  engorgement  of  the  stomach  are  always 
liable  to  be  accompanied  by  some  degree  of  atrophic  gastritis. 
The  disease  is  therefore  frequently  observed  in  valvular 
affections  of  the  heart,  emphysema,  fibroid  disease  of  the 
lungs,  atrophic  cirrhosis  of  the  liver,  and  in  cases  where  a 
tumour  exerts  direct  pressure  upon  the  portal  vein. 

(4)  Pernicious  anaemia  is  invariably  accompanied  by  a 
diffuse  atrophy  of  the  mucous  membrane  of  the  stomach  and 
intestines.  The  opinion  expressed  by  its  discoverer,  Samuel 
Fenwick,  regarding  its  causal  influence  upon  the  anaemia 
has  been  endorsed  by  many  subsequent  writers,  but  if  one 
may  judge  from  the  etiology  of  other  diffuse  forms  of  gastro- 
enteritis it  would  appear  more  probable  that  the  same  cause 
that  produces  the  haemolysis  is  also  responsible  for  the  destruct- 
ive inflammation  of  the  digestive  organs. 

(5)  Severe  gastroenteritis  leading  to  atrophy  is  a  common 
result  of  improper  feeding  in  early  life,  and  the  resultant 
inhibition  of  the  digestive  and  absorptive  processes  is  the  cause 
of  the  marasmus  of  infancy  (Chapter  VIII). 

(6)  Direct  injury  inflicted  upon  the  stomach  by  the  inges- 
tion of  strong  acids  or  alkalies  is  always  followed,  if  the  patient 
survives,  by  cicatrisation  of  the  inner  surface  of  the  organ  and 
a  complete  disappearance  of  the  gastric  glands. 

(7)  Finally,  it  would  seem  that  an  atrophy  of  the  secretory 
structures  of  the  stomach  is  a  natural  result  of  old  age.  In 
more  than  30  per  cent,  of  the  stomachs  removed  from  persons 
over  fifty  years  of  age  who  had  died  from  various  diseases  I 
found  microscopical  evidence  of  atrophy  in  the  pyloric  region 
of  the  organ,  while  in  people  over  seventy-five  a  large  part  of 
the  organ  may  be  affected  in  a  similar  manner.  There  can  be 
little  doubt,  therefore,  that  the  so-called  senile  dyspepsia  is 
caused  to  a  great  extent  by  retrograde  changes  affecting  the 
glandular  apparatus  of  the  alimentary  canal. 

Symptoms. — Atrophy  of  the  stomach  rarely  presents  any 


SYMPTOMS.  203 

symptoms  that  may  be  regarded  as  pathognomonic,  and  since 
the  diagnosis  depends  almost  entirely  upon  the  state  of  the 
gastric  secretion  as  determined  by  chemical  analysis,  much 
confusion  has  arisen  from  the  indiscriminate  inclusion  of  all 
cases  that  present  a  suppression  of  gastric  juice  under  the 
term  achyha  gastrica.  It  has  already  been  shown  that  this 
condition  of  anacidity  may  arise  from  neurasthenia,  hysteria, 
and  other  nervous  disorders  quite  independently  of  any 
organic  disease  of  the  stomach;  and  since  the  prognosis  of  the 
functional  and  organic  varieties  of  achylia  are  widely  different, 
it  is  obvious  that  atrophy  of  the  stomach  should  be  regarded 
as  a  clinical  entity. 

A  study  of  the  etiology  of  the  disease  indicates  that  cases 
of  atrophy  of  the  stomach  may  be  divided  into  four  clinical 
groups.  The  first  comprises  those  examples  of  the  complaint 
which  are  secondary  to  pernicious  anaemia,  the  symptoms  of 
which  necessarily  overshadow  those  of  the  gastric  complica- 
tion (Chapter  IX).  In  the  second  group  the  atrophy  is  the 
result  of  chronic  gastritis,  and  is  preceded  for  some  time  by 
indications  of  that  disease.  A  third  variety  ensues  from 
destruction  of  the  stomach  by  some  corrosive  fluid  that  had 
been  swallowed  either  by  accident  or  intention,  while  in  the 
fourth  the  disease  develops  as  a  consequence  of  old  age 
(Chapter  VIII). 

(i)  Gastric  Atrophy  in  Pernicious  Ancemia. — This  form  of 
the  complaint  is  equally  common  in  the  two  sexes.  In 
women  it  is  most  frequently  encountered  between  the  ages  of 
twenty  and  forty,  while  men  are  usually  affected  at  a  later 
period  of  hfe  (forty  to  sixty).  The  first  indications  of  ill-health 
consist  of  lassitude,  weakness,  palpitation,  and  dyspnoea  on 
exertion.  The  skin  and  mucous  membranes  become  mark- 
edly pale  and  gradually  acquire  a  lemon  tint,  and  from  time 
to  time  attacks  of  pyrexia  occur,  which  last  for  several  days 
and  are  accompanied  by  an  increase  of  anaemia  and  the  passage 
of  dark  coloured  urine.     The  spleen  and  liver  are  somewhat 


204    ATROPHY   OF   THE   MUCOUS    MEMBRANE    OF   THE   STOMACH. 

enlarged;  the  blood  is  pale  and  watery,  and  its  red  corpuscles 
are  greatly  diminished  in  number. 

The  gastric  phenomena  that  accompany  these  changes  in 
the  blood  resemble  those  of  chronic  gastroenteritis.  Loss 
of  appetite  is  invariably  present,  and  there  may  be  a  special 
distaste  for  meat,  but  vegetables  and  farinaceous  substances  arej 
usually  taken  with  a  certain  degree  of  relish.  Thirst  is  a 
constant  symptom  and  is  particularly  severe  at  night  and 
during  the  attacks  of  pyrexia.  At  first  fulness  after  meals, 
distention,  nausea,  and  excessive  flatulence  are  the  chief  causes 
of  complaint,  but  after  a  time  retching  and  vomiting  occur  in 
the  early  morning  and  after  meals.  The  bowels  are  confined, 
and  the  total  acidity  of  the  urine  is  persistently  greater  than 
under  normal  circumstances.  With  the  onset  of  a  febrile 
attack  all  these  symptoms  become  greatly  exaggerated,  and 
occasionally  a  form  of  gastric  intolerance  occurs  which  prevents 
the  administration  of  food  by  the  mouth.  Under  these  cir- 
cumstances nausea  and  retching  are  incessant  and  small 
quantities  of  alkaline  and  bile-stained  mucus  are  vomited  at 
intervals.  During  the  final  stages  of  the  complaint  the  symp- 
toms of  intestinal  indigestion  constitute  the  predominant 
feature  of  the  complaint.  The  constipation  is  now  replaced 
by  diarrhoea,  which  at  first  assumes  a  lienteric  character,  but 
soon  becomes  constant.  Gurgling  in  the  abdomen,  griping 
pains,  and  distention  of  the  intestines  with  gas  add  greatly 
to  the  general  discomfort,  emaciation  sets  in  and  the  patient 
becomes  too  feeble  to  walk.  Death  ensues  either  from 
asthenia  or  syncope. 

(2)  Atrophy  from  Chronic  Gastritis. — When  destruction  of 
the  gastrointestinal  mucosa  ensues  from  chronic  inflammation 
due  to  improper  food,  kidney  disease,  phthisis,  carcinoma, 
diabetes,  or  other  well-recognised  condition,  the  gradual 
development  of  inanition  accompanied  by  diarrhoea  will 
always  suggest  the  supervention  of  atropHyT^t  sHould  the 
antecedent  inflammation  of  the  alimentary  tract  have  been 


SYMPTOMS.  205 

caused  by  malaria  or  some  other  complaint  contracted  in  a  hot 
climate,  the,  primary  lesion  of  the  stomach  is  apt  to  be  over- 
looked and  the  symptoms  attributed  to  the  former  disease. 
In  cases  of  this  kind  a  chronic  state  of  ill-health  finds  its 
expression  in  constant  lassitude  and  debility,  accompanied  by  a 
marked  distaste  for  food,  progressive  emaciation,  and  anaemia. 
In  most  instances  fulness  and  discomfort  are  experienced 
immediately  after  meals,  followed  by  eructations  of  gas, 
flatulent  distention  of  the  abdomen,  and  a  lienteric  form  of 
diarrhoea;  but  occasionally  the  ingestion  of  any  kind  of  food 
gives  rise  to  severe  epigastric  pain,  while  vomiting  occurs  from 
time  to  time.  Examination  of  the  blood  shows  a  moderate 
diminution  of  the  number  of  red  corpuscles  and  haemoglobin, 
but  the  characteristic  changes  met  with  in  pernicious  anaemia 
are  never  observed.  Whatever  system  of  feeding  is  adopted, 
the  patient  steadily  loses  flesh  and  strength,  and  not  infre- 
quently suffers  from  dyspnoea  and  faintness  after  exertion  or 
from  constant  pain  in  the  head,  giddiness,  or  palpitation. 
Death  usually  ensues  from  pneumonia  or  other  intercurrent 
disease  or  from  asthenia. 

(3)  Atrophy  from  the  Ingestion  of  Corrosives. — In  most  of 
the  cases  of  this  nature  which  have  been  recorded,  the  patient 
had  swallowed,  either  by  accident  or  intent,  a  quantity  of 
sulphuric,  nitric,  hydrochloric,  or  carbolic  acid  or  a  strong 
solution  of  a  caustic  alkali.  If  life  is  preserved  the  violent 
inflammation  of  the  stomach  gradually  subsides  and  a  diffuse 
cicatrisation  of  the  inner  surface  of  the  viscus  ensues.  This 
sequence  of  events  gives  rise  to  the  series  of  symptoms  already 
described  under  the  title  of  acute  toxic  gastritis. 

The  stage  of  inflammation  follows  immediately  upon  the 
ingestion  of  the  irritant  poison  and  lasts  from  ten  days  to  six 
weeks.  It  is  characterised  by  gastric  intolerance.  The 
symptoms  which  portray  the  existence  of  atrophy  from  this 
cause  are  fulness  and  pain  after  meals,  excessive  flatulence, 
vomiting   after   meat   or   other  forms  of    nitrogenous    food, 


2o6   ATROPHY   OF   THE   MUCOUS   MEMBRANE    OF   THE   STOMACH. 

with  great  emaciation  and  debility.  As  long  as  the  intestine 
is  able  to  perform  its  duties  loss  of  flesh  does  not  of  necessity- 
occur,  but  as  a  rule  diarrhoea  with  flatulent  distention  of  the 
bowels  makes  its  appearance  within  a  few  months  and  the 
patient  gradually  sinks  from  inanition.  In  two  cases  which 
came  under  my  notice  death  resulted  from  an  extremely  rapid 
form  of  phthisis,  and  Robert  has  recorded  a  similar  instance. 
It  would  therefore  seem  that  a  sudden  and  total  failure  of 
gastric  digestion  may  so  affect  the  general  nutrition  as  to  favour 
the  inception  of  the  tubercle  bacillus.  / 

Chemistry  of  Digestion. — If  a  test-breakfast  be  admin- 
istered and  the  stomach  aspirated  one  hour  afterward,  the 
major  portion  of  the  meal  can  be  recovered.  This  is  probably 
due  to  the  gastrectasis  which  almost  invariably  accompanies 
true  atrophy  of  the  stomach  and  serves  to  distinguish  this 
disease  from  nervous  achylia  where  the  muscular  power 
of  the  stomach  remains  unaffected  for  a  long  period.  The 
particles  of  bread  which  remain  upon  the  filter-paper  are  some- 
what swollen,  but  they  fail  to  present  the  gelatinous  appearance 
which  is  so  characteristic  of  partial  digestion.  The  total 
acidity  of  the  filtrate  is  very  slight  and  rarely  exceeds  lo, 
while  in  many  cases  the  fluid  is  neutral  or  even  slightly  alkaline. 
Free  hydrochloric  acid  is  entirely  absent,  and  the  combined 
acid  either  exists  only  in  minute  quantity  or  is  completely 
wanting.  Lactic  acid  can  seldom  be  recognised,  but  if  the 
stomach  is  much  dilated  a  small  quantity  may  be  detected. 
The  reactions  for  peptone  and  propeptone  give  negative  results. 
The  most  careful  tests  may  also  fail  to  prove  the  existence  of 
pepsin  and  rennet,  and  lavage  performed  with  a  dilute  solution 
of  hydrochloric  acid  does  not  produce  a  medium  which  is 
capable  of  digesting  fibrine  or  curdling  milk  after  neutrahsation. 

It  is  usually  stated  that  mucus  is  invariably  absent  from 
the  gastric  contents,  but  this  is  a  mistake.  In  all  cases  of 
atrophy  secondary  to  chronic  inflammation  of  the  stomach 
mucus  is  still  secreted  by  those  parts  of  the  mucous  membrane 


DIAGNOSIS.  207 

which  have  escaped  entire  destruction,  and  Schmidt  has  shown 
that  in  many  cases  a  new  epithehum  is  formed,  similar  to  that 
met  with  in  the  intestine,  which  covers  portions  of  the  atrophic 
mucosa  and  secretes  mucus.  Even  when  the  inner  surface  of 
the  stomach  has  been  destroyed  by  a  corrosive  a  certain  amount 
of  mucus  can  still  be  detected  in  the  remnants  of  a  test  meal 
and  in  the  early  morning.  In  cases  of  nervous  achyha,  on 
the  other  hand,  the  gastric  contents  are  usually  devoid  of 
mucus. 

Prognosis. — The  prognosis  of  atrophy  of  the  stomach  de- 
pends to  a  great  extent  upon  its  cause.  In  pernicious  ansemia, 
carcinoma  of  the  breast  and  other  organs,  phthisis,  kidney 
disease,  diabetes,  and  other  organic  complaints  the  duration 
of  life  depends  upon  the  course  of  the  primary  malady,  and 
the  most  that  can  be  said  is  that  the  failure  of  gastric  digestion 
tends  to  hasten  the  fatal  termination.  Atrophy  of  the  stomach 
resulting  from  gastritis  of  uncertain  origin  may  exist  for  two 
or  even  three  years;  but  in  most  instances  the  concomitant 
atrophy  of  the  intestinal  mucous  membrane  interferes  with  the 
compensatory  action  of  the  alimentary  canal  which  is  of  such 
conspicuous  importance  in  nervous  achyha,  and  brings  life 
to  an  end  within  eighteen  months.  Extensive  destruction  of 
the  stomach  from  corrosives  usually  terminates  fatally  within 
two  years,  while  in  most  instances  phthisis,  pneumonia,  or 
oesophageal  obstruction  puts  an  end  to  existence  within  a 
much  shorter  period  of  time.  The  influence  of  the  atrophy 
in  early  life  and  old  age  will  be  considered  in  a  separate 
chapter  (Chapter  VIII). 

Diagnosis. — All  varieties  of  chronic  gastritis  are  apt  to 
terminate  by  atrophy,  and  consequently  diarrhoea  after  meals,  . 
failure  of  appetite,  loss'  of  flesh,  anaemia,  and  progressive? 
debility  should  always  receive  special  attention.  The  real 
diagnosis  of  the  complaint,  however,  is  based  upon  an  analysis 
of  the  gastric  contents  after  the  administration  of  a  test-meal. 
The  most  important  feature  of  this  investigation  is  the  marked 


2o8    ATROPHY   OF   THE   MUCOUS    MEMBRANE   OF   THE   STOMACH. 

reduction  of  the  total  acidity,  accompanied  by  the  complete 
disappearance  of  hydrochloric  acid  and  the  ferments.  In 
certain  cases  lavage  of  the  stomach  may  remove  small  shreds 
of  tissue  from  the  viscus,  which  on  microscopical  examination 
are  found  to  consist  of  minute  portions  of  mucous  membrane 
that  present  the  characteristic  signs  of  interglandular  gastritis 
with  atrophy  of  the  peptic  glands  (Einhorn). 

Atrophy  of  the  stomach  has  chiefly  to  be  distinguished  from 
achylia  gastrica,  carcinoma  of  the  stomach,  and  amyloid 
degeneration  of  the  gastric  mucosa. 

Cases  of  "achylia  gastrica"  are  usually  discovered  by 
accident  in  persons  who  present  no  symptoms  of  a  digestive 
derangement.  Emaciation  rarely  occurs  until  a  late  stage  of 
the  complaint,  and  is  then  very  gradual  in  its  progress.  Anor- 
exia, ansemia,  and  debility  are  absent,  pain  after  food  and 
vomiting  are  rarely  encountered,  and  diarrhoea  only  exists  if 
symptoms  of  intestinal  dyspepsia  have  recently  developed. 
In  most  instances  the  patient  is  the  subject  of  neurasthenia, 
hysteria,  tabes,  or  some  other  affection  of  the  nervous  system, 
and  there  is  no  history  of  antecedent  gastritis.  The  results  of 
a  gastric  analysis  are  very  similar  to  those  met  with  in  atrophy, 
but  it  can  usually  be  noted  that  in  achylia  the  remnants  of  the 
test-meal  are  scanty,  abnormally  dry,  and  devoid  of  mucus, 
while  gastrectasis  is  absent  until  an  advanced  stage  of  the 
nervous  complaint. 

Carcinoma  of  the  posterior  wall  of  the  stomach  attended 
by  chronic  gastritis  may  closely  resemble  atrophy  of  the 
gastric  mucosa  in  its  general  features.  Both  complaints 
are  accompanied  by  anorexia,  emaciation,  anaemia,  and 
symptoms  indicative  of  gastric  indigestion  and  by  signs  of 
moderate  gastrectasis.  It  may  usually  be  observed,  however, 
that  in  cancer  the  loss  of  flesh  and  strength  is  much  more 
rapid,  while  in  the  majority  of  cases  pain  after  food  and 
vomiting  are  conspicuous  features  of  the  disease.  Con- 
stipation is  far  more  common  than  diarrhoea,  the  epigastrium 


treat>j:ext.  209 

is  tender  upon  pressure,  and  oedema  of  the  feet  and  thrombosis 
of  veins  sometimes  occur. 

A  test-meal  shows  the  existence  of  food  retention  and  an 
excessive  secretion  of  mucus;  the  total  acidin.-  of  the  filtered 
contents  is  rarely  reduced  as  low  as  10.  combined  hydrochloric 
acid  may  usually  be  detected,  the  ferments  rarely  disappear 
completely,  and  in  many  instances  lactic  acid  exists  in  con- 
siderable quantity.  As  a  rule,  also,  altered  blood  is  present 
from  time  to  time  in  the  stomach,  and  the  Oppler-Boas 
bacillus  may  be  detected  by  the  microscope. 

Amyloid  degeneration  is  invariably  due  either  to  prolonged 
suppuration,  syphilis,  phthisis,  or  chronic  disease  of  the 
kidneys.  The  spleen  is  enlarged,  albumin  is  present  in  the 
urine  along  with  colloid  casts,  the  liver  is  increased  in  size. 
and  diarrhoea  is  a  prominent  feature  of  the  case.  These  facts 
considered  in  conjunction  with  the  prolonged  nature  of  the 
patient's  illness  seldom  render  the  diagnosis  a  matter  of  any 
serious  difficult}'. 

Treatment. — General. — It  is  important  to  preserve  the 
strength  as  far  as  possible,  and  consequently  overexertion 
must  be  prohibited  and  the  patient  should  be  encouraged  to 
recline  on  a  couch  or  in  an  easy-chair  in  the  open  air  and  to 
take  moderate  daily  exercise.  Owing  to  his  susceptibihty 
to  cold,  the  clothing  should  be  warm  without  being  unduly 
hea\y,  and  exposure  to  wet  must  be  carefully  avoided.  The 
meals  should  be  taken  at  regular  intervals,  and  all  solid 
articles  of  food  must  be  minced  or  passed  through  a  sieve  and 
well  masticated.  As  a  rule,  red  meats  are  difficult  of  digestion 
and  create  pain,  so  that  animal  food  should  be  restricted  to 
well-boiled  chicken,  sweetbread,  tripe,  cah's  head,  sheep's 
brains,  white  fish,  and  oysters.  Farinaceous  foods  usually 
agree  well,  and  rice,  tapioca,  sago,  potato,  peas,  lentils,  and 
oatmeal  may  be  employed  in  the  preparation  of  soups  and 
puddings.  Soft-boiled  or  poached  eggs  are  also  of  value. 
and  mav  be   dven  alons  with  bread  and  butter,   toast   or 


2IO   ATROPHY   OF   THE   MUCOUS   MEMBRANE    OF   THE   STOMACH. 

biscuits.  Butter  and  cream  are  easily  digested  if  the  intestine 
remains  unaffected,  but  milk  rarely  agrees  unless  well  diluted 
with  lime-water  or  peptonised.  Beer  and  spirits  must  be 
prohibited,  but  sometimes  a  little  hock  or  other  white  wine 
taken  with  the  meals  helps  to  improve  the  appetite. 

When  anaemia  is  a  marked  feature  of  the  case,  a  cautious 
trial  may  be  made  of  small  doses  of  arsenic  and  ammonio- 
citrate  of  iron,  but  these  drugs  rarely  agree  in  cases  where 
the  atrophy  has  been  preceded  by  symptoms  of  chronic  gas- 
tritis and  are  very  apt  to  excite  sickness  and  diarrhoea.  If 
gaseous  distention  occurs  after  meals,  carbolic  acid,  resorcine, 
cyllin,  or  other  antiseptic  remedy  may  be  prescribed,  or  a 
capsule  containing  3  minims  of  guaiacol  be  administered  after 
food.  Diarrhoea  is  combated  by  a  diet  of  peptonised  milk 
and  cream,  and  a  course  of  salicylate  of  bismuth  and 
compound  powder  of  opium. 

Owing  to  the  absence  of  the  gastric  secretion  in  these  cases, 
hydrochloric  acid  and  pepsin  are  usually  prescribed,  but 
unfortunately  this  attempt  to  supply  the  constituents  of  the 
gastric  juice  and  to  increase  the  powers  of  digestion  are 
rarely  of  much  value,  and  in  many  instances  the  acid  gives  rise 
to  pain.  The  sour  milk  prepared  in  the  manner  recom- 
mended by  Metchnikoff  ought  to  be  of  considerable  use  in 
these  cases  and  should  always  be  given  a  fair  trial.  Pan- 
creatin,  maltine,  lactopeptine,  and  peptenzyme  are  also  dis- 
appointing in  their  effects. 

If  gastrectasis  exists,  lavage  of  the  stomach  should  be 
performed  each  morning  before  breakfast,  and  occasionally 
massage  and  electricity  may  be  employed  with  advantage. 


CHAPTER  V. 

DYSPEPSIA  DUE  TO  A  DISTURBANCE  OF  THE  NERVOUS 
MECHANISM  OF  THE  STOMACH. 

(i)  Gastric  Hyperaesthesia.     (2)  Neurasthenia  Gastrica.     (3) 
Nervous    Eructation.     (4)  Habitual    Regurgitation. 

The  gastric  functions  are  so  directly  controlled  by  the  central 
nervous  system  that  few  diseases  of  the  brain  or  spinal  cord 
are  unattended  by  symptoms  referable  to  a  disturbance 
of  the  stomach  or  intestines,  while  in  many  cases  pain  in  the 
abdomen,  vomiting  or  constipation  precede  in  point  of  time 
the  development  of  the  phenomena  characteristic  of  the 
nervous  lesion.  When,  however,  the  various  disorders  of 
secretion  aheady  described  are  excluded  from  this  category, 
few  of  the  gastric  neuroses  are  found  to  present  that  con- 
glomeration of  symptoms  which  merits  the  term  "dyspepsia. " 
For  this  reason  only  two  complaints  can  be  accurately  described 
as  examples  of  nervous  indigestion,  namely,  hypersesthesia  of 
the  mucous  membrane  of  the  stomach  and  gastric  neurasthenia. 
Inasmuch,  however,  as  an  insufficiency  of  the  cardiac  sphincter 
of  nervous  origin  is  attended  by  symptoms  which  are  often, 
though  erroneously,  regarded  as  evidences  of  dyspepsia,  it 
appears  advisable  to  append  a  short  account  of  this  special 
condition  under  the  titles  of  nervous  eructation  and  habitual 
regurgitation. 

(i)   HYPERAESTHESIA  OF  THE  STOMACH. 

Under  normal  circumstances  the  various  processes  of 
digestion  are  not  accompanied  by  any  subjective  sensations 
and  a  healthy  individual  is  therefore  quite  unconscious  of 
his  possession  of  a  stomach;  but  if  from  any  cause  the  secretory 

211 


212  HYPER.ESXHESIA   OF   THE    STOMACH. 

or  motorial  functions  of  the  viscus  become  deranged  his  at- 
tention is  at  once  attracted  to  his  digestive  organs  by  reason 
of  the  pain,  distention,  or  flatulence  that  ensues  after  meals. 
In  like  manner,  an  exalted  sensibihty  of  the  inner  surface  of 
the  stomach  engenders  a  series  of  morbid  phenomena  when- 
ever the  hypersensitive  tissue  is  brought  into  contact  with 
food  or  even  with  its  own  secretion  in  a  condition  of  abnormal 
acidity. 

Etiology. — Gastric  hyperaesthesia  probably  occurs  during 
the  course  of  many  diseases,  both  functional  and  organic. 
Thus,  it  sometimes  manifests  itself  in  cases  of  cerebral  tumour 
and  meningitis,  and  may  prove  a  troublesome  complication  of 
locomotor  ataxia,  disseminated  sclerosis,  and  chronic  inflam- 
mation of  the  spinal  meninges.  In  neurasthenia  and  hysteria 
it  is  often  conspicuously  present,  and,  in  the  latter  complaint, 
an  access  of  pain  and  vomiting  from  this  cause  may  prove  the 
immediate  precursor  of  a  convulsive  seizure.  Certain  diseases 
of  the  stomach,  such  as  ulcer,  carcinoma,  and  syphilis,  owe 
many  of  their  protean  symptoms  to  the  coexistence  of  hyper- 
aesthesia, while  much  of  the  pain  that  attends  both  hyper- 
acidity and  hypersecretion  is  due  to  an  excessive  sensibility 
of  the  whole  of  the  inner  surface  of  the  organ. 

In  women,  prolonged  lactation,  menorrhagia,  severe  leu- 
corrhoea,  or  other  debilitating  conditions,  sometimes  give  rise 
to  the  complaint,  while  mental  overstrain,  bleeding  piles,  and 
venereal  excesses  are  often  responsible  for  its  development 
in  men.  The  practice  of  masturbation  in  early  life  is,  accord- 
ing to  my  experience,  a  very  common  cause  of  gastric  hyper- 
aesthesia in  both  sexes.  Direct  irritation  of  the  stomach  by 
long-continued  indulgence  in  stimulating  foods,  condiments, 
iced  water,  coffee,  or  alcohol,  or  by  the  administration  of  certain 
drugs  toward  which  the  individual  possesses  a  special  idio- 
syncrasy, such  as  quinine,  arsenic,  iodide  of  potassium,  sandal- 
wood oil,  salicylate  of  sodium,  etc.,  is  sometimes  responsible  for 
an  attack.     Tobacco  inhalation  and  chewing,  as  well  as  chlo- 


SYMPTOMS.  213 

roform  narcosis,  are  also  common  though  often  unsuspected 
causes  of  the  disorder.  A  sudden  return  to  a  full  diet  after 
long  abstention  from  solid  food  is  always  liable  to  be  followed 
by  hypersesthesia  of  the  stomach,  a  fact  which  serves  to  explain 
the  occurrence  of  pain  and  vomiting  after  acute  starvation  and 
also  the  troublesome  dyspepsia  which  occasionally  develops 
during  convalescence  from  typhoid  fever. 

Of  all  the  conditions,  however,  which  are  prone  to  excite 
the  disorder,  chlorosis  is  infinitely  the  most  important  in  this 
country,  and  consequently  the  great  majority  of  the  patients 
are  females  between  fifteen  and  thirty  years  of  age  who  have 
previously  suffered  from  increasing  pallor  of  the  lips,  dyspnoea, 
and  other  indications  of  anaemia.  According  to  my  hospital 
statistics,  10 . 2  per  cent,  of  all  dyspeptics  suffer  from  this  par- 
ticular complaint,  while  in  those  relating  to  private  practice  the 
percentage  frequency  of  this  disease  was  only  i .  6.  This  differ- 
ence is  not  due  to  class  influence,  but  merely  to  the  fact  that 
the  complaint  is  so  easily  cured  by  appropriate  treatment  that 
comparatively  few  find  it  necessary  to  seek  the  advice  of  a 
specialist.  As  might  be  inferred  from  the  relative  frequency 
of  chlorosis  in  the  two  sexes,  about  92  per  cent,  of  the  cases 
occur  in  women.  It  would  therefore  appear  that  while  gastric 
hypersesthesia  is  often  a  secondary  feature  of  some  other  and 
more  important  disease,  its  most  characteristic  form  is  en- 
countered in  young  women  who  are  the  subjects  of  anaemia. 

Symptoms. — If  a  case  of  primary  gastric  hyperaesthesia 
be  carefully  watched  throughout  its  course,  it  will  be  found 
to  present  four  stages  of  development,  each  of  which  is 
characterised  by  some  feature  of  clinical  importance. 

The  first  or  initial  stage  is  accompanied  by  symptoms 
which  for  the  most  part  are  common  to  several  other  va- 
rieties of  indigestion.  In  the  early  morning  the  patient  com- 
plains of  giddiness  or  faintness  upon  rising  from  bed,  which 
is  sometimes  associated  with  flatulence,  headache,  nausea,  or 
palpitation.      The  appetite  is  rarely  impaired,  but  immediately 


214  HYPERESTHESIA   OF   THE   STOMACH. 

after  each  meal  fulness  and  discomfort  are  experienced  in  the 
epigastrium  and  left  hypochondrium,  which  culminate  in  an 
aching  or  burning  pain  that  tends  to  radiate  over  the  adjacent 
parts  of  the  thorax.  Gaseous  eructations  occur  from  time 
to  time  and  are  followed  by  nausea.  The  bowels  are  usually 
confined,  but  sometimes  a  lienteric  form  of  diarrhoea  occurs 
after  meals.  The  patient  is  markedly  anaemic,  irritable, 
capricious  in  her  tastes,  and  suffers  either  from  amenorrhoea 
or  from  irregularity  of  the  catamenia.  The  tongue  is  pale  and 
flabby,  the  urine  copious  and  often  phosphatic,  and  profuse 
perspirations  are  apt  to  occur  after  slight  exercise  or  excitement. 

The  second  stage  of  the  complaint  is  characterised  by  the 
substitution  of  veritable  pain  for  the  previous  discomfort. 
Immediately  after  eating  a  burning  pain  is  experienced  in  the 
region  of  the  stomach,  which  continues  with  varying  severity 
for  one  or  two  hours,  and  is  accompanied  by  nausea,  flatulence, 
and  abdominal  distention.  These  symptoms  are  induced  by 
any  form  of  nourishment,  and  although  most  prominent  after 
indulgence  in  meat  they  are  also  readily  excited  by  hot  and 
cold  liquids  and  even  by  milk.  The  bowels  are  invariably 
confined,  the  appetite  is  diminished,  and  thirst  at  night  is  a 
frequent  cause  of  complaint. 

After  a  variable  period  the  occurrence  of  vomiting  ushers 
in  the  third  stage  of  the  disease.  At  first  the  attacks  of  emesis 
are  only  occasional  and  merely  lead  to  a  partial  evacuation 
of  the  stomach;  but  the  tendency  to  sickness  rapidly  increases 
until  vomiting  takes  place  after  each  meal  and  occasions 
the  loss  of  the  greater  part  of  the  ingesta.  This  symptom 
presents  three  pecuhar  features:  In  the  first  place,  unhke 
that  which  occurs  in  cases  of  gastric  ulcer,  the  rejection  of 
the  food  does  not  exert  any  notable  effect  upon  the  pain; 
and  even  when  the  stomach  has  been  completely  evacuated, 
the  pain  only  subsides  in  a  gradual  manner;  in  other  words, 
the  inner  surface  of  the  stomach  continues  to  ache  after  the 
immediate  cause  of  its  irritation  has  been  removed.     Secondly, 


SYMPTOMS.  215 

although  vomiting  may  have  continued  for  several  weeks, 
the  patient  rarely  exhibits  any  obvious  signs  of  emaciation, 
and  if  she  be  weighed  regularly  the  loss  of  weight  appears 
trifling  when  compared  with  the  apparent  severity  of  the 
gastric  symptoms.  Thirdly,  unlike  most  other  diseases  in 
which  vomiting  is  a  prominent  symptom,  the  appetite  con- 
tinues surprisingly  good,  and  the  patient  will  often  finish  a 
meal  after  vomiting  the  first  portion  of  it.  Occasionally, 
however,  the  appetite  diminishes  when  the  emesis  develops, 
or  the  fear  of  inducing  pain  and  sickness  prevents  the  girl 
from  indulging  her  desire  for  food.  At  this  period  the  anaemia 
makes  rapid  progress,  headache  is  frequent,  and  a  feeling  of 
exhaustion  is  experienced  after  the  least  exertion.  The  bowels 
are  obstinately  confined. 

The  advent  of  the  fourth  stage  is  heralded  by  a  general 
failure  of  nutrition  and  by  the  disappearance  of  the  pain. 
This  latter  feature  is  probably  due  to  the  fact  that  emesis 
occurs  immediately  after  food,  and  hence  there  is  no 
time  for  the  development  of  pain.  If  seen  for  the  first  time 
at  this  period  of  the  complaint,  the  case  is  very  Hable  to  be 
mistaken  for  one  of  cerebral  vomiting;  but  careful  attention 
to  the  history  will  always  elicit  the  fact  that  pain  immediately 
after  food  had  existed  for  some  time  before  the  attacks  of 
emesis  commenced,  while  optic  neuritis  and  other  evidences 
of  cerebral  disease  are  absent.  Occasionally  a  severe  attack 
of  retching  is  accompanied  by  shght  hgemorrhage,  but  true 
hsematemesis  is  never  observed.  The  bowels  are  very  confined, 
the  anaemia  is  profound,  and  a  sense  of  intense  weakness  often 
obhges  the  patient  to  remain  in  bed.  In  some  instances 
attacks  of  partial  syncope  occur  from  time  to  time  and  give 
rise  to  great  anxiety.  The  ease  with  which  the  ideopathic 
variety  of  the  disorder  is  cured  by  medical  treatment  renders 
a  fatal  termination  comparatively  rare,  but  occasionally 
death  ensues  from  exhaustion  or  from  some  intercurrent 
affection  of  the  lungs. 


2l6  HYPER.^STHESIA   OF   THE    STOMACH. 

Physical  Signs. — The  most  important  indication  of  gastric 
hypercesthesia  consists  of  an  abnormal  sensitiveness  to  pressure 
of  the  whole  region  of  the  abdomen  occupied  by  the  stomach. 
When  the  viscus  is  empty  the  hyperassthetic  area  may  be 
localized  to  the  left  hypochondrium;  but  after  a  meal  or  if 
the  organ  be  artificially  inflated,  the  tender  region  becomes 
enlarged  and  is  found  to  correspond  exactly  with  the  dimensions 
of  the  exposed  stomach.  Occasionally  the  skin  below  the 
left  breast  or  beneath  the  inferior  angle  of  the  left  scapula  is 
also  hypersensitive.  On  the  other  hand,  the  locahzed  tender- 
ness of  the  epigastrium  so  characteristic  of  gastric  ulcer  is 
invariably  absent.  The  stomach  itself  rarely  presents  any 
signs  of  dilatation,  and  if  the  vomiting  is  excessive  the  viscus 
usually  appears  smaller  than  normal.  The  gastric  contents 
obtained  after  a  test-meal  vary  in  different  cases,  being  normal 
in  character  in  about  60  per  cent,  somewhat  deficient  in 
hydrochloric  acid  in  10  per  cent.,  and  exhibiting  moderate 
hyperchlorhydria  in  30  per  cent.  Lactic  acid  is  always  absent, 
and  the  motorial  functions  of  the  organ  are  normal.  Oc- 
casionally scybalous  masses  may  be  felt  in  the  transverse  and 
descending  portions  of  the  colon.  Examination  of  the  blood 
shows  a  great  diminution  of  haemoglobin,  the  percentage 
amount  of  which  may  fall  as  low  as  30  in  severe  cases,  and 
rarely  exceeds  50. 

Diagnosis. — There  are  two  diseases  with  which  gastric 
hypersesthesia  is  often  confounded,  both  of  which  are  unduly 
frequent  in  young  and  anaemic  women,  namely,  gastric  ulcer 
and  a  painful  neurosis  of  the  colon. 

In  gastric  ulcer  pain  rarely  occurs  until  after  the  completion 
of  a  meal,  and  unless  the  ulcer  is  situated  close  to  the  oesopha- 
geal opening  it  never  ensues  immediately  a  mouthful  of  food 
has  been  swallowed.  It  is  chiefly  produced  by  the  direct 
irritation  of  solids,  and,  unlike  the  pain  of  the  functional 
disorder,  is  at  once  relieved  by  a  milk  diet.  The  pain  is 
referred  to  the  epigastrium,  which  presents  a  small  area  of 


DIAGNOSIS.  217 

localised  tenderness.  The  rest  of  the  gastric  region  is  free 
from  discomfort  upon  pressure,  and  cutaneous  hypersesthesia 
is  rarely  encountered.  Vomiting  is  much  less  frequent  than  in 
gastric  hypersesthesia,  is  only  provoked  by  food,  occurs  at  the 
crisis  of  a  painful  attack,  and  by  ridding  the  stomach  of  its 
irritant  contents  the  emesis  at  once  reheves  the  pain.  Hsem- 
atemesis  occurs  in  the  majority  of  the  cases  of  ulcer  and  is 
copious  in  amount.  Rest  in  bed  and  a  milk  diet  rapidly 
relieve  the  symptoms  of  the  organic  disease,  but  produce  little 
effect  in  cases  of  hyperagsthesia.  The  gastric  contents  in  cases 
of  chronic  ulcer  usually  exhibit  hyperchlorhydria. 

A  painful  contraction  of  the  transverse  colon  excited  by  the 
introduction  of  food  into  the  stomach  is  a  very  troublesome 
complaint  in  certain  anaemic  girls  who  are  members  of  a 
tuberculous  family  or  who  have  suffered  in  early  life  from 
migraine.  The  pain  occurs  immediately  after  food,  is  often 
very  severe,  and  may  be  accompanied  by  vomiting.  It 
may  be  noticed,  however,  that  it  is  usually  excited  by  solid 
food  or  by  hot  fluids,  that  instead  of  being  localised  to  the 
gastric  region  it  is  referred  to  the  whole  of  the  upper  part 
of  the  abdomen,  and  that  careful  inquiry  will  elicit  the  fact 
that  it  commences  in  the  right  hypochondrium  and  extends 
thence  across  the  belly  about  the  level  of  the  navel.  The  pain 
is  far  more  intense  than  that  of  gastric  hypersesthesia,  is 
colicky  in  character,  and  the  complaint  is  readily  cured  by  the 
administration  of  suitable  aperients  and  by  the  prohibition  of 
fruits  and  green  vegetables. 

Chronic  gastritis,  for  which  gastric  hypersesthesia  is 
occasionally  mistaken,  is  rare  in  young  women  unless  they  are 
the  subjects  of  valvular  disease  of  the  heart,  phthisis,  chronic 
nephritis,  or  are  addicted  to  alcohol.  Actual  pain  after  food 
is  rarely  complained  of,  but  about  an  hour  or  more  after  meals 
a  sensation  of  discomfort  and  fulness  occurs,  followed  by 
flatulence,  acidity,  and  nausea.  Vomiting  may  occur  in  the 
early  morning  or  after  meals,  and  in  both  cases  relieves  the 


2l8  HYPERESTHESIA   OF   THE   STOMACH. 

unpleasant  symptoms  which  were  previously  present.  The 
ejecta  are  largely  mixed  with  mucus  and  usually  deficient  in 
hydrochloric  acid.  The  appetite  is  diminished,  loss  of  flesh  is 
a  prominent  symptom,  and  the  bowels  are  irregular  rather 
than  confined.  Sahne  purgatives,  combined  with  careful 
regulation  of  the  diet  and  a  course  of  alkalies  and  bismuth, 
usually  relieve  the  complaint. 

Treatment. — If  any  doubt  exists  as  to  whether  a  patient 
is  suffering  from  ulcer  or  from  hypersesthesia  it  is  wise  to 
assume  the  presence  of  the  more  serious  complaint,  and  to 
treat  the  case  in  accordance  with  this  supposition.  This  line 
of  practice  is  not  only  of  value  from  the  point  of  view  of  safety, 
but  is  in  itself  an  important  help  to  diagnosis,  since  the  pain  and 
vomiting  due  to  ulcer  invariably  subside  when  the  patient 
remains  in  bed  and  is  confined  to  a  milk  diet,  while  in  cases  of 
hypersesthesia  the  symptoms  are  usually  aggravated  by  such 
measures. 

If  pain  and  vomiting  are  severe  the  patient  should  maintain 
a  recumbent  position  for  a  few  days,  but  confinement  to  bed  for 
more  than  a  week  is  rarely  necessary.  In  recent  cases  cold 
compresses  over  the  region  of  the  stomach  often  help  to 
relieve  the  symptoms,  but  in  the  chronic  complaint  a  small 
blister  should  be  applied  to  the  skin  of  the  epigastrium  or  the 
part  be  painted  each  night  with  the  liniment  of  iodine. 

Diet. — A  milk  diet  often  appears  to  increase  the  pain  and 
it  is,  therefore,  usually  advisable  to  prescribe  semisolids  rather 
than  liquids.  With  this  object  lightly  boiled  or  poached  eggs, 
milk  puddings,  jellies,  and  clear  soups  are  at  first  allowed, 
to  be  followed  subsequently  by  white  fish,  chicken,  game, 
rabbit,  sweetbread,  tripe,  calf's  head,  with  a  httle  potato, 
cauliflower,  or  spinach.  At  a  later  period  the  patient  resumes 
her  ordinary  diet. 

The  medicinal  treatment  of  the  complaint  should  be 
chiefly  directed  toward  the  cure  of  the  anaemia  or  the  correction 
of  any  other  condition  which  may  seem  to  have  excited  the 


TREATMENT.  219 

complaint.  When  constipation  has  existed  for  some  time, 
and  especially  if  the  colon  is  loaded  with  faeces,  half  an  ounce 
to  an  ounce  of  castor  oil  should  be  given  each  morning  before 
breakfast;  or  if  the  patient  cannot  take  the  oil  a  full  dose  of 
the  mistura  alba  or  other  saline  may  be  substituted  for  it. 
Subsequently  a  daily  action  of  the  bowel  should  be  secured 
by  the  administration  of  an  iron  and  aloes  pill  night  and 
morning  after  food  or  of  some  other  mild  aperient  each  night, 
such  as  cascara  and  maltine,  the  confection  of  senna  and 
sulphur,  or  the  compound  liquorice  powder.  For  the  treat- 
ment of  the  anaemia  nothing  is  of  greater  value  than  the 
ammonio-citrate  of  iron,  lo  to  15  grains  of  which  may  be 
combined  with  a  drachm  of  the  solution  of  bismuth,  and 
given  three  times  a  day  after  meals.  These  simple  measures 
rarely,  if  ever,  fail  to  produce  an  immediate  improvement  in 
all  the  aspects  of  the  case,  and  should  be  continued  until  a 
cure  seems  to  have  been  accomplished. 

Gastric  hyperaesthesia  of  secondary  origin  rarely  requires 
separate  treatment.  If,  however,  its  symptoms  are  severe 
and  produce  a  deleterious  effect  upon  the  nutrition,  it  may  be 
necessary  to  adopt  certain  remedial  measures.  In  cases  of 
organic  disease  of  the  brain  and  spinal  cord  a  bismuth  mixture 
containing  morphine,  codeine,  chloretone,  or  some  other 
sedative  usually  affords  most  relief,  while  in  neurasthenia  and 
hysteria  chief  dependence  should  be  placed  upon  the  special 
treatment  of  these  complaints.  A  pill  containing  one-quarter 
of  a  grain  or  more  of  nitrate  of  silver  given  twice  a  day  before 
meals  is  often  of  value.  This  latter  remedy  is  also  recom- 
mended for  the  variety  of  gastric  hyperaesthesia  which  ensues 
from  tobacco  poisoning  (Rosenheim).  Cessation  of  all 
medication,  with  the  exception  of  a  small  dose  of  mercury  and 
chalk  each  night,  will  soon  relieve  the  form  of  the  complaint 
which  results  from  the  abuse  of  drugs. 

The  fact  that  gastric  hyperaesthesia  frequently  relapses 
should  never  be  overlooked,  and  the  patient  must  be  warned 


220  GASTRIC   NEURASTHENIA. 

to  have  recourse  again  to  treatment  immediately  the  symptoms 
show  signs  of  recrudescence. 

(2)  GASTRIC  NEURASTHENIA. 

(Nervous  Dyspepsia.) 

This  variety  of  dyspepsia  is  a  combined  form  of  neurosis 
which  affects  the  sensory,  motor,  and  secretory  functions  of 
the  gastrointestinal  tract. 

Etiology. — According  to  Rosenthal,  more  than  two-thirds 
of  the  cases  are  accompanied  by  neurasthenia,  and  Glax  lays 
great  stress  upon  the  fact  that  symptoms  of  nervous  dyspepsia 
almost  invariably  precede  the  manifestation  of  the  general 
complaint.  It  may  therefore  be  inferred  that  the  predis- 
posing causes  of  the  disease  are  practically  the  same  as  those 
of  general  neurasthenia.  Continued  mental  overstrain,  fre- 
quent and  severe  forms  of  psychic  excitement,  shock,  ex- 
haustion from  venereal  or  alcohohc  excesses,  self-abuse, 
spermatorrhoea,  prolonged  deprivation  of  food,  and  a  pro- 
tracted residence  in  hot  climates  are  fruitful  causes  of  the 
complaint  among  men,  while  in  women  repeated  child-birth, 
excessive  leucorrhoea,  ansemia,  menorrhagia,  and  diseases  of 
the  uterus  or  its  appendages  are  equally  important  factors 
in  its  production.  The  disease  is  common  about  the  age 
of  puberty  and  is  very  apt  to  develop  when  the  body  has 
undergone  exceptionally  rapid  growth.  In  both  sexes,  but 
especially  in  boys,  masturbation  in  early  life  is  a  common, 
though  often  unsuspected  cause,  while  in  girls,  profuse  and 
frequent  menstruation  sometimes  appears  to  determine  the 
onset  of  the  complaint.  Occasionally  the  first  symptoms  date 
from  an  injury,  such  as  concussion  of  the  brain  or  spine, 
the  fracture  of  a  long  bone,  or  a  severe  shake  in  a  carriage 
accident,  and  in  a  few  instances  they  have  been  observed  to 
follow  immediately  after  a  surgical  operation.  The  con- 
valescent period  of  certain  infectious  diseases  is  particularly 


SYMPTOMS.  221 

apt  to  be  complicated  by  gastric  neurasthenia,  more  especially 
that  of  influenza,  erysipelas,  enteric  fever,  mumps,  and  malaria; 
while  in  rare  instances  an  attack  of  gastroenteritis,  induced  by 
poisonous  food  or  drugs  or  even  the  administration  of  a 
drastic  purge,  has  appeared  to  act  as  the  exciting  cause. 
Both  sexes  are  equally  prone  to  the  disease,  but  it  may  usually 
be  observed  that  men  are  most  frequently  affected  before  the 
age  of  thirty,  while  women  are  unduly  susceptible  to  it  between 
the  ages  of  twenty  and  forty. 

If  one  may  judge  from  general  statements,  neurasthenia 
gastrica  is  more  common  in  France  and  England  than  in  other 
parts  of  Europe  and  is  exceptionally  frequent  in  America.  It 
is  also  apt  to  attack  certain  families  and  is  particularly  rife 
among  the  Jews  and  the  natives  of  India  who  come  to  this 
country  for  the  purposes  of  study.  According  to  my  own 
experience,  a  close  relationship  exists  between  the  gastric 
disorder  and  tuberculosis,  and  persons  who  have  previously 
suffered  from  an  attack  of  phthisis  are  unduly  prone  to  fall 
victims  to  the  nervous  complaint.  With  regard  to  its  incidence 
upon  different  classes  of  the  community  somewhat  contra- 
dictory opinions  are  entertained,  but  all  writers  are  agreed  that 
it  is  much  more  frequent  among  those  whose  occupations 
entail  continual  worry  or  excitement,  such  as  stockbrokers, 
lawyers,  teachers,  artists,  actors,  and  musicians,  than  in  other 
spheres  of  hfe.  My  statistics  show  that  gastric  neurasthenia 
constituted  3  per  cent,  of  the  cases  of  dyspepsia  that  presented 
themselves  for  hospital  treatment,  and  13 . 2  per  cent,  of  those 
met  with  in  private  practice. 

Symptoms. — It  is  convenient  to  distinguish  two  chnical 
forms  of  gastric  neurasthenia,  according  as  the  symptoms  with 
which  they  are  accompanied  are  mild  or  severe.  In  other 
varieties  of  indigestion  such  a  classification  would  merely 
amount  to  a  discussion  of  the  early  and  late  manifestations  of 
the  complaint,  but  in  this  particular  disorder  cases  of  a  mild 
type  continue  to  exhibit  similar  symptoms  throughout  their 


222  GASTRIC   NEURASTHENIA. 

entire  course,  while  those  which  belong  to  the  severe  form 
present  serious  phenomena  from  the  outset  and  undergo  little 
or  no  change  until  convalescence  supervenes.  It  may  be, 
of  course,  that  the  two  types  really  depend  upon  different 
nervous  lesions,  but  since  their  symptoms  appear  to  differ 
only  in  degree,  it  is  necessary  to  regard  them  as  varieties  of  the 
same  complaint. 

(i)  The  Mild  Form. — This  variety  is  by  far  the  most 
common  and  is  characterised  by  an  absence  of  the  emaciation 
and  cerebral  depression  that  invariably  accompany  the  severe 
form.  In  spite  of  their  incessant  and  varied  complaints,  the 
subjects  of  this  disorder  rarely  appear  ill  or  anaemic,  and  on 
the  contrary  usually  continue  well-nourished  and  of  a  healthy 
aspect.  The  appetite  is  subject  to  much  variation,  being 
sometimes  irregular  and  capricious,  at  other  times  excessive, 
while  occasionally  complete  anorexia  may  supervene.  As  a 
rule,  the  desire  for  food  bears  an  intimate  relation  to  the  mental 
condition.  Thus,  if  the  patient  be  removed  from  his  usual 
environment,  be  allowed  to  mix  in  congenial  society,  or  to 
pursue  some  form  of  amusement  which  enables  him  to  forget 
for  a  time  his  worries  and  troubles,  it  will  usually  be  observed 
that  he  is  able  to  eat  with  relish  and  to  digest  articles  of  food 
which  under  ordinary  circumstances  give  rise  to  much  dis- 
comfort. Conversely,  anything  that  tends  to  depress  the 
mind  or  add  to  his  anxieties  is  at  once  followed  by  an  exacer- 
bation of  the  dyspeptic  symptoms  and  perhaps  by  a  complete 
failure  of  appetite.  Another  striking  feature  of  the  complaint 
is  the  absence  of  any  relationship  between  the  quantity  or 
quality  of  the  food  and  the  severity  of  the  subsequent  indiges- 
tion. A  large  meal  does  not  necessarily  cause  greater  dis- 
comfort than  a  small  one,  and  the  same  articles  which  one  day 
give  rise  to  the  most  wretched  and  protracted  suffering  may  be 
taken  on  the  next  without  any  ill  effects.  In  many  instances 
the  patient  always  feels  at  his  best  immediately  after  a  meal, 
and  during  the  hour  which  succeeds  the  ingestion  of  food  he  is 


SYMPTOMS.  223 

able  to  transact  business  with  a  clear  head,  to  write,  teach, 
or  compose  with  facihty  and  even  brilhance.  In  other  cases 
the  symptoms  of  maldigestion  ensue  before  he  has  left  the 
table,  and  within  a  short  time  he  will  complain  of  an  aching 
void  in  the  region  of  the  stomach  which  nothing  but  additional 
nourishment  will  satisfy.  Weight,  oppression,  and  distention 
are  the  terms  most  often  employed  to  describe  the  sensations 
that  ensue  after  meals,  but  occasionally  severe  attacks  of  pain, 
similar  to  those  of  gastralgia,  are  experienced.  Constant 
belching  constitutes  an  important  symptom  in  many  instances, 
but  if  the  gas  be  collected  and  examined  it  is  found  to  consist 
almost  entirely  of  atmospheric  air  that  has  been  swallowed 
with  the  food.  Pyrosis,  preceded  by  sharp  pain  at  the  base 
of  the  thorax,  may  recur  at  short  intervals,  but  regurgitations 
of  acid  are  never  met  with  unless  the  disease  is  associated 
with  hyperacidity. 

Nausea  is  a  constant  cause  of  complaint,  but  vomiting  is 
exceptional.  During  an  access  of  indigestion  the  face  often 
flushes,  the  nose  and  ears  burn,  the  head  feels  heavy,  and 
the  greatest  disinclination  is  expressed  for  mental  or  physical 
exertion.  In  some  attacks  severe  palpitation  of  the  heart 
occurs,  attended  by  shortness  of  breath,  throbbing  in  the  head, 
or  a  sense  of  impending  dissolution.  The  tongue  usually 
continues  moist  and  clean,  the  urine  is  scanty  and  phosphatic, 
the  pulse  is  small  and  feeble,  and  the  temperature  of  the  body 
is  depressed. 

Although  the  disease  is  regarded  as  an  affection  of  the 
stomach,  the  functions  of  the  intestines  are  also  invariably 
disturbed.  During  the  period  of  digestion  the  whole  of  the 
alimentary  tract  may  become  distended  with  gas,  and  the 
patient  is  much  perturbed  by  loud  rumbling  noises  in  the 
abdomen  which  no  effort  upon  his  part  is  able  to  subdue. 
Constipation  is  an  invariable  feature,  and  often  precedes  the 
development  of  the  gastric  phenomena.  It  increases  in  severity 
as  time  goes  on ,  and  proves  peculiarly  intractable  to  the  ordi- 


224  GASTRIC   NEURASTECENIA. 

nary  methods  of  treatment.  The  stools  consist  of  small  round 
or  oval  masses  of  hard  and  dry  faeces,  coated  with  an  opaque 
mucus,  or  present  the  appearance  of  long  flat  ribbons  which 
may  cause  them  to  be  mistaken  for  worms. 

Burkart  has  described  the  existence  of  certain  tender  spots 
in  the  abdomen  which  he  considers  pathognomonic  of 
nervous  dyspepsia,  deep  pressure  with  the  hand  over  the 
situation  of  the  superior  hypogastric,  coeHac,  and  aortic 
plexuses,  giving  rise  to  a  severe  and  characteristic  attack  of 
pain.  Leven  has  also  drawn  attention  to  an  abnormal  sensi- 
bility of  the  solar  plexus,  which  can  apparently  be  detected 
by  pressure  over  the  median  line  of  the  abdomen  immediately 
below  the  ensiform  cartilage.  There  is  no  doubt  that  persons 
suffering  from  gastric  neurasthenia  frequently  experience  pain 
when  sufficiently  strong  pressure  is  made  in  one  or  other  of 
these  situations,  but  this  phenomenon  is  by  no  means  char- 
acteristic of  the  disease,  nor  is  it  by  any  means  a  constant 
feature  (Bouveret,  Ewald,  Richter). 

It  was  originally  stated  by  Leube  that  nervous  dyspepsia 
occurs  independently  of  any  perversion  of  secretion  or  motihty, 
and  that  if  the  stomach  is  examined  seven  hours  after  a  full 
meal  it  is  invariably  found  to  be  empty.  Since  the  pubhcation 
of  his  memoir  in  1879,  the  chemistry  of  digestion  has  been 
made  the  subject  of  much  investigation,  and  both  the  methods 
employed  by  Leube  and  the  results  he  obtained  have  been 
severely  criticised  by  Stiller,  Ley  den,  Glax,  Bouveret,  and  other 
modem  investigators.  In  fourteen  cases  of  nervous  dyspepsia 
carefully  studied  by  Herzog,  the  motor  power  of  the  stomach 
was  found  to  be  enfeebled  in  nine  and  normal  in  five.  Among 
the  former  series  three  presented  a  normal  acidity,  one  sub- 
acidity,  and  five  hyperacidity,  while  in  the  latter  the  gastric 
secretion  was  normal  in  one  instance  and  contained  an  excess 
of  hydrochloric  acid  in  the  other  four.  It  would  thus  appear 
that  only  one  case  out  of  the  fourteen  fulfilled  Leube's 
definition  of  the  disease. 


SYMPTOMS.  225 

(2)  The  Severe  Form. — In  this  variety  all  the  symptoms 
previously  mentioned  are  exaggerated  and  the  patient  suffers 
from  indigestion  after  every  meal,  whatever  be  its  composition. 
Actual  pain  may  exist,  or  vomiting  may  ensue  at  the  height 
of  digestion,  and,  as  a  rule,  great  complaint  is  made  of  a  sense 
of  coldness  and  vacuity  in  the  abdomen  which  requires  the 
further  ingestion  of  food  for  its  relief.  But  the  chief  features 
that  distinguish  this  type  of  the  disorder  from  the  mild 
variety  are  steady  emaciation  and  a  profound  constitutional 
disturbance  that  follows  the  administration  of  purgatives. 
Loss  of  flesh  is  a  constant  symptom,  but  it  varies  in  degree 
in  different  cases  and  at  different  periods  of  the  complaint. 
In  elderly  people  the  average  loss  of  weight  per  week  may 
amount  to  a  pound  or  more,  and  although  the  progress  of  ema- 
ciation often  halts  from  time  to  time,  an  actual  gain  is  rarely 
observed.  This  is  especially  noticeable  since  the  patient 
usually  consumes  more  food  than  he  did  when  in  good  health. 
The  skin  also  becomes  dry  and  rough,  the  face  thin  and 
haggard,  and  in  many  instances  a  cachexia  develops  closely 
akin  to  that  of  carcinoma.  In  young  individuals,  on  the  other 
hand,  a  rapid  loss  of  weight  is  often  interrupted  by  periods 
of  improvement,  during  which  they  recover  the  flesh  and 
strength  that  they  had  lost,  without  having  altered  the  diet 
or  lost  the  distressing  symptoms  of  indigestion. 

As  a  rule,  constipation  exists  in  a  most  intractable  form, 
and,  like  that  which  accompanies  the  mild  type  of  the  com- 
plaint, is  associated  with  the  passage  of  hard,  dry,  attenuated 
or  "rabbit-dung"  stools,  mixed  with  mucus.  Occasionally, 
however,  as  Moebius  has  pointed  out,  the  constipation  may 
be  replaced  by  a  form  of  diarrhoea  which  occurs  immediately 
after  meals,  and  causes  the  elimination  of  the  food  before  it 
has  undergone  digestion.  In  such  cases  the  introduction  of 
nourishment  into  the  stomach  seems  to  excite  a  strong  peri- 
stalsis of  the  whole  of  the  ahmentary  tract,  attended  by 
griping  pains  in  the  abdomen  and  sometimes  by  nausea.  The 
15 


2  26  GASTRIC   NEURASTHENIA.    . 

subjects  of  gastric  neurasthenia  can  rarely  tolerate  aperients, 
and  even  enemata  often  give  rise  to  the  most  depressing 
symptoms;  indeed,  it  is  a  constant  assertion  that  life  is  only 
tolerable  as  long  as  the  bowels  remain  inactive.  In  every 
instance  where  an  evacuation  follows  the  use  of  an  aperient, 
the  patient  is  overcome  by  nausea,  faintness,  or  exhaustion, 
and  even  when  the  medicine  fails  to  act  it  may  occasion  the 
same  distressing  symptoms  and  necessitates  confinement  to 
bed  for  the  day.  Mental  depression,  closely  allied  to  hypo- 
chondriasis, is  frequently  present,  and  the  patient  spends 
most  of  his  time  in  consulting  one  doctor  after  another  under 
the  firm  conviction  that  he  is  suffering  from  some  organic  disease 
which  nobody  can  diagnose. 

The  other  symptoms  that  accompany  severe  gastric  neu- 
rasthenia are  less  important  but  of  the  most  varied  description. 
In  some  instances  the  appetite  is  either  entirely  absent  or  is 
replaced  by  a  loathing  of  food  which  is  even  more  intense 
than  that  met  with  in  cancer  of  the  stomach  or  anorexia  nervosa; 
while  in  others  a  canine  hunger  exists  and  the  patient  devours 
immense  quantities  of  food  at  short  intervals  in  order  to  ward 
ofif  the  nausea  and  faintness  that  ensue  whenever  the  stomach 
becomes  partially  empty.  Sometimes  a  spasmodic  form  of  dys- 
phagia makes  its  appearance,  or  a  paresis  of  the  cardiac  orifice 
permits  the  frequent  regurgitation  of  mouthfuls  of  acid  chyme. 
Vomiting  of  the  hysterical  type  is  occasionally  met  with,  and 
attacks  of  gastralgia  are  apt  to  occur  from  time  to  time  and 
may  simulate  biliary  colic  or  even  perforation  of  the  stomach. 
Both  hyperacidity  and  hypersecretion  sometimes  accompany 
the  nervous  disorder  and  give  rise  to  the  symptoms  and  signs 
characteristic  of  these  conditions.  In  other  instances,  again, 
the  patient  constantly  experiences  unpleasant  smells  or  a 
peculiar  taste,  or  suffers  from  profuse  salivation.  Diarrhoea 
is  a  common  symptom  in  some  cases,  and  several  actions  of 
the  bowel  take  place  in  rapid  succession  whenever  the  in- 
dividual is  excited  or  suffers  from  nervous  apprehension.     An- 


SYMPTOMS.  227 

other  curious  intestinal  condition  consists  in  the  formation 
of  locahzed  contractions  and  isolated  gaseous  distentions  of 
the  caecum  or  the  flexures  of  the  colon.  Under  these  circum- 
stances there  is  a  sense  of  fulness  and  tenderness  in  the  affected 
regions  which  disappears  with  a  gurgling  noise  and  the  passage 
of  flatus  or  of  a  thin,  bile-stained  fluid. 

Cherchewsky  has  described  a  form  of  nervous  ileus,  the 
symptoms  of  which  closely  resemble  those  of  internal  strangu- 
lation, but  after  persisting  for  several  hours  they  suddenly 
subside  with  the  evacuation  of  a  large  quantity  of  gas.  Neu- 
ralgic pains  are  extremely  common,  and  usually  affect  the 
temporal,  supraorbital,  or  intercostal  nerves.  Occasionally 
the  whole  of  the  spine  becomes  extremely  tender  and  percussion 
over  it  gives  rise  to  excessive  pain  or  faintness.  Attacks  of 
palpitation,  attended  by  a  quick  or  irregular  pulse,  are  apt  to 
supervene  after  excitement  or  fatigue,  and  extreme  breath- 
lessness  may  occur  under  similar  conditions.  Vertigo  is  often 
complained  of  both  when  the  stomach  is  empty  and  after  a 
full  meal,  and  may  closely  resemble  the  form  that  accompanies 
disease  of  the  semicircular  canals.  Disinclination  for  exercise, 
both  mental  and  physical,  invariably  exists,  and  the  limbs 
are  often  described  as  heavy  and  cold  or  affected  by  sensations 
of  burning,  numbness,  or  formication.  The  sexual  functions 
are  depressed,  and  profound  exhaustion  is  experienced  after 
intercourse.  Erections  are  of  short  duration,  and  emissions 
ensue  rapidly  and  are  apt  to  recur  at  short  intervals  without 
obvious  cause.  Finally,  such  cerebral  symptoms  as  cephalalgia, 
strabismus,  diplopia,  insomnia,  and  paresis  of  the  extremities 
are  occasionally  encountered  and  may  occasion  much  anxiety. 

The  secretory  and  motor  functions  of  the  stomach  are 
always  seriously  affected.  During  the  whole  period  of 
digestion  splashing  sounds  may  be  obtained  below  the  level 
usually  occupied  by  the  viscus,  and  undigested  food  may  be 
evacuated  by  a  tube  more  than  seven  hours  after  a  meal. 
The  total  acidity  of  the  gastric  contents  may  not  exceed  15, 


228  GASTRIC   NEURASTHENIA. 

and  free  hydrochloric  acid  is  often  absent.  Absorption  both 
from  the  stomach  and  intestines  is  much  delayed,  and  it  is 
probable  that  the  secretions  of  the  pancreas  and  bowel  are 
either  diminished  or  so  altered  in  character  that  the  carbo- 
hydrates and  fats  undergo  little  or  no  digestion  in  the  body. 
In  this  connection  it  is  interesting  to  observe  that  Jiirgens  is 
said  to  have  demonstrated  degenerative  changes  in  the  plexuses 
of  Meissner  and  Auerbach  in  the  cases  of  nervous  dyspepsia 
which  he  examined  after  death. 

Complications. — When  the  severe  form  has  existed  for 
some  time  it  is  apt  to  become  complicated  by  dilatation  of  the 
stomach,  enteroptosis,  and  mucous  colitis. 

Gastrectasis  is  frequently  met  with  at  an  advanced  stage 
of  the  complaint  and  may  develop  in  two  ways.  Most  com- 
monly it  ensues  as  the  result  of  simple  myasthenia  of  the 
viscus  and  is  due  in  all  probability  to  defective  innervation  of 
the  stomach.  In  other  instances  a  deficiency  of  hydrochloric 
acid  in  the  gastric  secretion  favours  fermentation  of  the  food, 
with  the  result  that  the  mucous  membrane  becomes  constantly 
irritated  by  the  acid  products  of  decomposition  and  at  the  same 
time  is  overdistended  by  the  gases  evolved  during  the  process. 
This  condition  of  muscular  insufficiency  is  easily  recognised 
by  the  fact  that  the  stomach  contains  undigested  food  seven 
hours  after  a  meal,  and  is  probably  responsible  in  part  for  the 
rapid  emaciation  that  invariably  ensues  when  this  complication 
becomes  established. 

Enteroptosis  is  much  more  common  in  women  than  in  men, 
being  predisposed  to  by  relaxation  of  the  abdominal  wall 
consequent  upon  repeated  pregnancies  and  the  habit  of 
wearing  tight  corsets.  Neurasthenia  probably  increases  the 
tendency  to  downward  displacement  of  the  viscera  by  the  loss 
of  abdominal  fat  and  the  increased  weight  of  the  dilated 
stomach  with  which  it  is  so  often  accompanied.  The  symp- 
toms and  signs  of  gastroenteroptosis  are  discussed  in  detail 
in  Chapter  VI. 


COMPLICATIONS.  229 

Mucous  colitis  is  very  apt  to  supervene  in  severe  cases  of 
nervous  dyspepsia,  but  is  chiefly  met  with  in  females.  The 
faeces-,  deprived  of  moisture  by  their  long  retention  in  the  large 
intestine,  excite  an  inflammatory  condition  j)f_the_mucojus 
membrane  of  the  colon  that  is  attended  by  a  copious  secretion 
of  mucus.  In  the  early  morning  the  patient  is  awakened  by 
attacks  of  colicky  pain  in  the  region  of  the  caecum  or  sigmoid 
flexure,  which  are  sometimes  followed  by  several  small  evacu- 
ations of  mucus.  At  other  times  of  the  day  and  more  especially 
after  meals,  solid  material  is  voided  in  the  form  of  hard, 
rounded  masses  which  are  covered  with  mucus  and  sometimes 
stained  with  blood,  while  occasionally  the  motion  consists 
entirely  of  long  strings  of  slime  or  small  pieces  of  the  lining 
membrane  of  the  large  bowel.  These  symptoms  may  occur 
each  day  or  they  may  appear  in  the  form  of  short  attacks 
which  persist  for  several  days  and  are  accompanied  by  moder- 
ate pyrexia.  In  this  latter  variety  the  stools  are  frequent, 
composed  almost  entirely  of  blood  and  mucus,  and  their 
evacuation  is  accompanied  by  much  tenesmus.  The  com- 
plaint is  very  difficult  to  cure  and  may  persist  for  a  long  time 
after  the  other  symptoms  of  the  gastric  disorder  have  subsided. 

Prognosis. — It  is  usually  possible  to  divide  the  course 
of  the  disease  into  three  periods :  The  first,  or  period  of  aggra- 
vation, is  characterised  by  the  gradual  increase  of  emacia- 
tion and  the  development  of  the  various  symptoms  of  dis- 
ordered digestion;  in  the  second,  or  stationary  period,  the 
patient  ceases  to  lose  weight,  but  the  subjective  phenomena 
undergo  little  change;  while  in  the  third,  or  convalescent  stage, 
the  weight  of  the  body  increases  and  improvement  occurs  in  all 
the  aspects  of  the  case.  As  a  rule,  the  disease  lasts  from  eigh- 
teen months  to  two  years,  but  it  may  persist  for  three  or  even 
four  years.  The  older  the  patient  the  more  intractable  does 
the  complaint  become,  while  in  young  persons  recovery  often 
takes  place  within  a  few  months.  Death  occasionally  occurs 
in  the  severe  form  from  profound  failure  of  nutrition  aggravated 


230  GASTRIC   NEURASTHENIA. 

by  persistent  insomina,  but  not  infrequently  the  fatal  termina- 
tion is  attributable  to  tuberculosis  or  some  other  intercurrent 
complaint. 

Diagnosis. — Gastric  neurasthenia  is  not  accompanied  by 
any  pathognomonic  symptoms  or  physical  signs,  and  it  is  there- 
fore necessary  to  consider  each  case  in  its  entirety  before  arriving 
at  a  diagnosis.  Three  points  are,  however,  always  worthy  of 
special  attention.  In  the  first  place,  the  gastric  disorder  is 
invariably  accompanied  by  indications  of  general  neuras- 
thenia, and  its  symptoms  vary  both  in  their  nature  and  severity 
according  to  the  state  of  the  nervous  system.  Secondly,  the 
discomfort  experienced  after  meals  bears  no  relation  to  the 
quantity  or  quality  of  the  food,  since  at  one  time  the  patient 
is  able  to  digest  with  ease  and  comfort  articles  of  diet  which 
at  another  give  rise  to  the  most  violent  manifestations  of 
dyspepsia.  Thirdly,  the  results  of  analyses  of  the  contents 
of  the  stomach  performed  at  intervals  vary  almost  as  much 
as  the  symptoms;  at  one  time  the  secretion  of  gastric  juice 
being  much  depressed,  while  at  another  evidences  of  hyper- 
chlorhydria  may  be  forthcoming. 

Cancer  of  the  stomach  is  the  disease  which  is  most  frequently 
confounded  with  the  severe  form  of  the  neurosis.  This  error 
of  diagnosis  is  particularly  apt  to  be  made  when  the  neoplasm 
pursues  a  latent  course  for  several  months  and  is  unaccom- 
panied either  by  tumour,  hsematemesis,  or  suppression  of 
hydrochloric  acid.  As  a  rule,  however,  careful  consideration 
will  show  that  whereas  the  subject  of  gastric  cancer  has  enjoyed 
excellent  health  prior  to  the  onset  of  his  present  complaint, 
the  nervous  dyspeptic  has  suffered  for  some  time  from  symp- 
toms characteristic  of  neurasthenia.  In  carcinoma  the  gas- 
tric phenomena  steadily  progress  in  spite  of  all  treatment,  the 
appetite  fails,  loss  of  flesh  is  severe  and  never  alternates  with 
periods  of  improvement,  pain  after  food  is  more  troublesome, 
while  vomiting  almost  invariably  occurs  at  some  period  of  the 
complaint.     The  gastric   secretion  gradually  diminishes,  and 


DIAGNOSIS.  231 

lactic  acid  fermentation  occurs  in  a  large  number  of  cases. 
Ansemia  always  accompanies  carcinoma  of  the  stomach,  and 
the  disease  rarely  lasts  for  more  than  eighteen  months.  On 
the  other  hand,  even  the  most  severe  cases  of  gastric  neuras- 
thenia exhibit  considerable  variations  in  the  severity  of  their 
symptoms;  the  appetite  is  often  good  and  may  be  excessive; 
the  process  of  emaciation  is  interrupted  by  periods  of  several 
weeks  during  which  the  patient  may  regain  the  weight  previously 
lost;  severe  pain  and  vomiting  after  meals  are  rarely  en- 
countered; the  lips  and  conjunctivae  usually  retain  their  nor- 
mal colour;  hsematemesis  never  occurs,  and  lactic  acid  can 
never  be  detected  in  the  contents  of  the  stomach.  The 
nervous  disease  may  last,  with  remissions,  for  several  years, 
and  is  apt  to  recur  should  the  patient  suffer  from  another 
breakdown. 

Chronic  gastritis  differs  in  many  important  respects  from 
neurasthenia  gastrica.  Vomiting  is  a  frequent  symptom  both 
in  the  early  morning  and  after  meals,  and  the  ejecta  always 
contain  an  excess  of  mucus.  The  appetite  is  usually  dimin- 
ished, and  is  never  excessive;  emaciation  is  gradual  and  slight 
in  degree;  discomfort,  flatulence,  and  acidity  are  constant 
phenomena  and  show  little  variation  from  day  to  day,  and 
symptoms  of  neurasthenia  are  absent.  The  inflammatory 
disease  can  usually  be  traced  either  to  abuse  of  alcohol,  errors 
of  diet,  or  to  organic  disease  of  some  important  organ  of  the 
the  body.  Strict  attention  to  diet  with  appropriate  treatment 
produces  a  rapid  improvement. 

Ulcer  of  the  stomach  of  the  "dyspeptic"  variety  has  occa- 
sionally been  mistaken  for  nervous  indigestion.  In  all  obscure 
cases  it  is  therefore  wise,  as  Leube  suggests,  to  try  the  effects 
of  treatment  for  ten  days  before  giving  a  definite  diagnosis, 
since  rest  in  bed  and  a  milk  diet  usually  remove  the  pain  after 
food  which  is  due  to  ulceration,  while  the  symptoms  of  neuras- 
thenia gastrica  are  often  exaggerated  rather  than  relieved  by  a 
similar  treatment.     It   is   also  to   be   observed  that   chronic 


232  GASTRIC   NEURASTHENIA. 

ulcer  is  usually  attended  by  hypersecretion,  while  this  dis- 
order of  secretion  is  infrequent  in  severe  nervous  dyspepsia 
and  is  apt  to  be  replaced  by  subacidity. 

The  diagnosis  of  appendicular  hypersecretion  from  gastric 
neurasthenia  has  already  been  discussed  (Chapter  II). 

Treatment. — General. — The  measures  usually  recom- 
mended for  general  neurasthenia  are  also  indicated  in  cases  of 
nervous  dyspepsia.  The  patient  should  be  encouraged  to 
pursue  a  definite  line  of  treatment,  and  be  constantly  reassured 
as  to  the  non-existence  of  organic  disease.  In  mild  cases  he 
may  be  directed  to  follow  his  usual  vocation,  provided  it  is 
not  of  too  arduous  a  nature,  to  devote  an  adequate  time  to  his 
meals,  to  go  to  bed  at  a  reasonable  hour,  and  to  avoid  adven- 
titious forms  of  excitement  and  unnecessary  fatigue. 

Sexual  intercourse  is  particularly  harmful  in  many  cases, 
and  should  always  be  restricted  as  far  as  possible.  Change 
of  air  seldom  fails  to  afford  relief  if  care  be  taken  to  avoid 
humid  and  enervating  localities.  In  most  instances  high 
altitudes  are  most  beneficial,  and  a  residence  in  Switzerland 
or  in  Scotland  during  the  summer  and  autumn  seldom  fails 
to  improve  the  appetite  and  to  remove  most  of  the  symptoms 
of  indigestion.  When  much  physical  enfeeblement  exists  a 
voyage  to  Australia  is  of  greater  value.  As  a  rule,  the  southern 
and  southwestern  parts  of  England  do  more  harm  than  good, 
and  many  persons  who  endeavour  to  regain  their  health  by 
a  holiday  at  Bournemouth,  Torquay,  the  Isle  of  Wight,  or  in 
Devonshire  return  home  in  a  worse  condition.  Of  the  inland 
health  resorts  Malvern  and  Ilkley,  in  the  north,  and  Hindhead, 
in  the  south,  are  the  best,  and  there  is  seldom  any  objection  to 
the  east  coast  during  the  warmer  months  of  the  year.  In 
every  case  the  patient  must  be  impressed  with  the  fact  that  a 
complete  rest  is  the  main  object  of  his  enforced  absence  from 
home,  and  he  should  consequently  free  himself  completely 
from  business  worries  and  remain  away  for  at  least  two  months. 
Short  holidays  are  quite  useless,  and  week-end  visits  only 


TREATMENT.  233 

promote  exhaustion.  Owing  to  the  important  influence  of 
environment,  the  patient  should  be  surrounded  by  cheerful 
associates,  and  all  news  of  a  depressing  or  irritating  character 
withheld  from  him  as  far  as  possible. 

In  the  severe  form  of  the  disease,  accompanied  by  rapid 
wasting  of  the  soft  tissues,  it  is  advisable  to  confine  the  patient 
to  bed  for  a  month  or  six  weeks  and  to  try  the  effects  of  a  full 
milk  diet  combined  with  massage  and,  if  necessary,  electricity. 
The  prohibition  of  literature  and  the  visits  of  friends  is  usually 
harmful  owing  to  the  inherent  tendency  to  melancholia,  and 
in  many  cases  where  an  effort  is  made  to  procure  complete 
isolation,  the  patient  throws  off  all  restraint  and  refuses  to 
subject  himself  any  longer  to  the  treatment. 

In  every  instance  the  condition  of  the  generative  organs 
requires  special  attention,  and  careful  enquiry  should  be  made 
concerning  self-abuse,  spermatorrhoea,  and  venereal  excesses, 
with  the  view  of  removing  these  potent  causes  of  nervous 
exhaustion.  Electricity  is  often  of  value  both  in  relieving 
the  gastric  symptoms  and  in  the  treatment  of  the  constipation. 
For  the  stomach  a  constant  current  of  3  to  5  milliamperes  is 
passed  through  the  epigastric  region  for  twenty  minutes  daily, 
the  negative  electrode  being  applied  over  the  lower  dorsal 
region  and  the  positive  one  immediately  below  the  left  costal 
margin.  Einhorn  and  others  prefer  direct  electrisation  of  the 
organ  by  means  of  a  metallic  wire  inserted  into  the  ordinary 
stomach-tube,  but  the  procedure  is  unpleasant  to  the  patient 
and  tedious  of  application.  When  electricity  is  employed  for 
constipation,  one  pole  is  inserted  into  the  rectum  and  the 
other,  consisting  of  a  large  metal  disc,  is  successively  applied 
to  the  surface  of  the  abdomen  at  different  points  along  the 
course  of  the  large  intestine.  The  interrupted  current  is  to  be 
preferred  to  the  constant  one,  and  each  sitting  should  last  for 
about  half  an  hour.  This  electrical  treatment  may  be  advan- 
tageously combined  with  massage  of  the  colon,  but  the  latter 
must  be  avoided   when    symptoms   of  mucous  colitis  exist. 


234  GASTRIC   NEURASTHENIA. 

If  anorexia  is  severe  it  may  be  necessary  to  resort  to  forcible 
feeding  through  a  tube. 

Diet. — The  fact  that  the  dyspepsia  is  only  slightly  influenced 
by  the  nature  of  the  food  renders  it  inexpedient  to  prescribe 
a  strict  dietary.  As  a  rule,  an  excess  of  innutritious  liquids, 
such  as  beef  tea,  broths,  tea,  and  mineral  waters  tends  to 
distend  the  stomach  and  to  increase  the  feehng  of  discomfort; 
while  green  vegetables  and  fruit  almost  invariably  disagree 
and  must  therefore  be  avoided.  The  meals  should  be 
moderate  in  quantity,  composed  of  materials  that  are  easily 
digested,  and  should  be  taken  at  intervals  of  three  hours. 
In  the  case  of  an  excessive  craving  for  nourishment  between 
meals,  egg  and  milk,  a  hard-boiled  egg,  or  a  cup  of  milk-cocoa 
may  be  allowed.  The  advisability  of  a  pure  milk  diet  must 
depend  upon  the  state  of  the  gastric  secretion.  In  the  mild 
form  of  the  complaint,  where  the  secretory  and  motor  powers 
of  the  stomach  are  usually  unaffected,  five  pints  of  warm  milk 
a  day,  in  divided  doses,  either  with  or  without  hme-water,  form 
an  excellent  substitute  for  other  forms  of  food,  and  usually 
promote  the  formation  of  fat  and  muscle.  On  the  other  hand, 
in  the  severe  form  of  the  disease  a  failure  of  the  gastric  secretion 
renders  an  excess  of  raw  milk  very  liable  to  disagree,  and  it 
should  therefore  be  peptonised  or  well  diluted  before  its 
administration.  Sometimes  Horlick's  malted  milk  proves 
of  use  when  the  fresh  form  is  inadmissible,  or  the  patient 
may  be  persuaded  to  take  one  of  the  patent  digested  foods 
in  preference  to  the  ordinary  forms  of  nourishment.  Milk 
soured  with  lactobacilline  is  useful  in  many  cases.  In  every 
instance  mastication  must  be  thoroughly  performed,  a  sufficient 
time  be  allowed  for  each  meal,  and  no  exercise  permitted  for 
an  hour  afterward. 

Medicinal. — The  choice  of  drugs  depends  upon  the  state  of 
the  gastric  secretion.  When  hyperacidity  accompanies  the 
nervous  disorder  an  alkahne  mixture  composed  of  bicarbonate 
of  sodium,  carbonate  of  bismuth,  and  glycerin  may  be  given 


TREATMENT.  235 

two  hours  after  each  meal,  or  a  compound  bismuth  lozenge 
may  be  sucked  at  intervals  during  the  course  of  digestion. 
As  a  rule,  however,  the  severe  form  of  the  complaint  is  accom- 
panied by  a  marked  deficiency  of  gastric  secretion,  and  it  is  in 
these  cases  that  hydrochloric  acid  is  of  much  value.  In  most 
instances  it  is  sufficient  to  prescribe  fifteen  drops  of  the  dilute 
acid  after  each  meal,  but  sometimes  a  wineglassful  of  a  2  or  3 
per  1,000  solution  of  hydrochloric  acid  at  the  end  of  each  re- 
past appears  to  be  more  beneficial.  The  various  digestives, 
such  as  pepsin,  pancreatin,  lactopeptin,  and  papain,  are  rarely 
of  any  decided  use,  nor  does  the  administration  of  takadiastase 
or  maltine  appear  to  influence  the  processes  of  digestion  in  a 
beneficial  manner.  Tablets  of  lactobacilline  rarely  possess 
any  value.  The  treatment  of  the  constipation  is  always  a 
matter  of  great  difficulty,  owing  to  the  exhaustion  that  often 
follows  the  use  of  purgatives.  In  most  cases  a  trial  should 
be  made  in  the  first  instance  of  a  tablespoonful  of  glycerin 
each  morning  before  breakfast,  or  of  a  small  dose  of  mercury 
and  chalk,  cascara,  or  euonymin,  combined  with  rhubarb  and 
hyoscyamus,  every  evening  after  the  last  meal.  Sahne  aperi- 
ents and  natural  aperient  waters  should  always  be  avoided,  as 
their  employment  invariably  increases  the  general  symptoms 
of  distress.  In  severe  cases  reliance  should  be  placed  almost 
entirely  upon  enemata,  soap  and  water,  or  warm  water  contain- 
ing glycerin  or  castor  oil  being  employed  for  the  purpose. 
Another  useful  method  is  the  injection  of  warm  olive  oil  into 
the  bowel  at  atmospheric  pressure.  At  first  half  a  pint  may 
be  given  every  alternate  morning,  but  as  the  patient  improves 
the  injection  need  only  be  repeated  every  third  or  fourth  day 
and  the  amount  of  the  oil  may  be  gradually  diminished. 

In  all  cases  the  general  health  should  receive  attention. 
If  symptoms  of  hysteria  exist  a  course  of  bromides  combined 
with  valerian  often  gives  relief.  Anaemia  usually  requires  the 
exhibition  of  one  of  the  bland  preparations  of  iron,  with  which 
arsenic  and  nux  vomica  can  be  combined  if  necessary.     In 


236  NERVOUS   ERUCTATION. 

young  persons  cod-liver  oil  and  the  compound  syrup  of  hypo- 
phosphites  are  often  of  great  value  in  improving  the  state  of 
the  general  nutrition. 

(3)  NERVOUS  ERUCTATION. 

Eructation  of  gas  from  the  stomach  occurs  under  many 
conditions.  In  healthy  individuals  a  certain  amount  of  air  is 
usually  swallowed  with  the  food  and  is  apt  to  be  returned 
within  a  short  time  after  the  repast;  while  the  use  of  efferves- 
cent drinks  and  sparkling  mineral  waters  is  always  followed  by 
slight  eructation  of  carbonic  acid  gas.  Again,  every  form  of 
indigestion  is  accompanied  in  a  greater  or  lesser  degree  by 
the  formation  of  gases  in  the  stomach,  and  in  many  cases  the 
chief  symptoms  of  the  complaint  are  due  to  the  distention  of 
the  viscus  by  these  products  of  fermentation.  But  in  the  dis- 
order which  is  known  as  "nervous  eructation"  the  only  abnor- 
mal symptom  consists  of  a  noisy  belching,  which  comes  on 
independently  of  food  and  may  persist  with  occasional  inter- 
missions for  weeks  or  months. 

Etiology. — Nervous  eructation  is  a  comparatively  rare 
complaint,  and  is  chiefly  encountered  in  neurasthenic  and 
hysterical  persons.  It  is  far  more  common  in  women  than  in 
men,  and  usually  develops  between  fourteen  and  twenty-five 
years  of  age.  Two  or  more  members  of  the  same  family  may 
suffer  in  the  same  manner  and  there  can  be  Httle  doubt  that 
imitation  often  plays  an  important  part  in  its  causation.  Occa- 
sionally men  of  middle  age  are  attacked  by  it  after  a  severe 
mental  or  physical  shock,  or  it  may  develop  at  this  period  of 
hfe  without  obvious  cause.  The  worst  case  that  has  ever 
come  under  my  notice  occurred  in  a  barrister,  who  on  account 
of  the  unpleasant  and  intractable  nature  of  his  disorder  was 
obliged  to  give  up  his  profession  and  to  live  in  seclusion. 

Symptoms. — The  belching  is  caused  by  bubbles  of  gas, 
which  ascend  the  oesophagus  in  rapid  succession  and  burst 
in  the  pharynx  with  explosive  force.     As  a  rule,  each  eruct- 


ETIOLOGY.  237 

ation  is  accompanied  by  a  double  noise,  the  component 
parts  of  which  are  separated  from  one  another  by  a  shght 
but  appreciable  interval.  The  first  is  short,  sharp,  and  metal- 
lic in  character  and  is  obviously  caused  by  the  bursting  of  the 
bubble  of  gas,  while  the  second  is  much  more  prolonged  and 
of  a  deeper  tone  and  is  due  to  secondary  vibrations  of  the  soft 
palate  which  cause  an  echo  in  the  vault  of  the  pharynx  and  in 
the  mouth.  The  latter  can  easily  be  felt  when  a  hand  is  placed 
upon  the  neck  of  the  patient.  The  noise  is  repeated  at  irregu- 
lar intervals,  sometimes  recurring  two  or  three  times  a  minute, 
while  at  others  hardly  a  couple  of  seconds  intervene  between 
successive  belchings.  The  eructation  is  not  arrested  by  meals, 
although  it  usually  ceases  during  sleep,  and  it  may  be  brought 
on  at  any  time  by  excitement,  anger,  fatigue,  or  even  by  the 
visit  of  an  unsympathetic  friend.  Occasionally  pressure  upon 
the  throat,  palpation  of  the  epigastrium,  or  depression  of  the 
tongue  with  a  spatula  will  provoke  an  attack.  In  a  case 
recorded  by  Bouveret  slight  pressure  upon  the  scar  of  a  former 
burn  was  sufficient  to  induce  a  violent  seizure.  In  most  cases 
the  complaint  pursues  an  irregular  course,  the  attacks  lasting 
on  each  occasion  for  several  days  or  weeks,  and  subsiding 
suddenly  without  obvious  reason;  but  occasionally,  and  espe- 
cially in  men,  the  disease  presents  few  or  no  intermissions  and 
is  practically  incurable.  In  other  respects  the  patients  appear 
to  enjoy  excellent  health,  the  appetite  continues  good,  the  nutri- 
tion is  well  maintained,  and  symptoms  of  dyspepsia  are  uni- 
formly absent.  In  chronic  cases,  however,  the  wearisome  and 
apparently  hopeless  nature  of  the  complaint  may  induce  melan- 
cholia with  suicidal  tendencies,  and  is  often  associated  with 
progressive  debility. 

Etiology. — If  the  eructated  gas  be  collected  and  measured 
it  is  astonishing  how  small  an  amount  is  found  to  be  brought 
up  on  each  occasion,  while  analysis  shows  that  it  is  devoid  of 
odour  and  is  composed  entirely  of  atmospheric  air  (Poengsen, 
Hoppe-Seyler).     It   therefore    differs    in   a   marked   manner 


238  NERVOUS    ERUCTATION. 

from  the  gas  that  is  regurgitated  in  ordinary  cases  of  flatulence, 
which  is  always  considerable  in  quantity  and  consists  of  a 
mixture  of  nitrogen,  carbon  dioxide,  and  hydrogen,  with  a 
variable  amount  of  marsh  gas  and  other  compounds. 

Two  explanations  have  been  offered  concerning  the  mechan- 
ism by  which  atmospheric  air  gains  an  entrance  to  the  stomach. 
According  to  Oser,  the  stomach  forms  an  elastic  sac,  the  cavity 
of  which  is  diminished  by  the  contraction  of  the  circular 
fibres  of  its  muscular  coat,  but  is  augmented  by  the  contraction 
of  the  longitudinal  fibres.  In  this  way  the  organ  exerts  an 
aspiratory  effect,  air  being  sucked  into  it  by  the  one  mechanism 
and  expelled  by  the  other.  On  the  other  hand,  Bouveret  has 
shown  that  in  many,  if  not  in  all,  cases  of  nervous  eructation,  a 
clonic  spasm  of  the  pharynx  exists  which  gives  rise  to  the 
deglutition  of  air.  According  to  this  observer,  with  whose 
statements  my  own  observations  are  in  complete  accord,  not 
only  can  the  clonic  spasm  of  the  pharynx  be  detected  by  the 
rhythmical  movement  of  the  larynx,  but  if  auscultation  be 
made  over  the  stomach  a  bruit  caused  by  the  irruption  of  a 
bubble  of  gas  into  the  viscus  can  be  heard  after  each  deglutition. 
As  soon  as  the  stomach  becomes  moderately  distended  in  this 
manner,  antiperistaltic  movements  of  the  organ  set  in,  which 
have  the  effect  of  driving  small  quantities  of  gas  through  the 
patulous  cardia  into  the  oesophagus  and  thence  into  the 
pharynx.  Occasionally,  however,  air  cannot  be  heard  to 
enter  the  stomach  in  the  manner  described,  so  it  is  probable 
that  in  some  cases,  at  any  rate,  the  bubble  only  penetrates  a 
certain  distance  down  the  oesophagus  before  it  is  expelled  by 
contractions  of  that  tube.  If  a  gag  is  inserted  into  the  mouth 
or  the  tongue  be  held  down,  the  clonic  contractions  of  the 
pharynx  are  impeded  or  entirely  prevented,  and  the  eructations 
cease. 

Treatment. — In  hysterical  females  the  complaint  may 
usually  be  cured  by  general  treatment  and  by  appropriate 
suggestion.     The  exhibition  of  bromides,  valerian,  and  iron 


HABITUAL   REGURGITATION.  239 

is  of  much  value,  and  the  bowels  should  be  maintained  in 
regular  action  by  suitable  aperients.  The  most  effective 
method  of  treatment  in  my  experience  consists  of  the  passage 
of  a  full-sized  tube  into  the  stomach  and  its  maintenance  in 
that  position  for  twenty  minutes  on  each  occasion.  In  more 
obstinate  cases  it  may  be  necessary  to  administer  a  constant 
current  through  the  tube,  and  to  apply  repeated  bhsters  to 
the  epigastrium.  When  the  disease  develops  in  adults  without 
obvious  cause,  its  violence  may  be  allayed  by  the  insertion  of 
a  gag  so  as  to  keep  the  teeth  apart,  or  of  an  instrument  to 
depress  the  tongue,  but  both  these  expedients  are  only  of 
temporary  value,  and  the  disease  usually  defies  every  effort  to 
cure  it. 

(4)  HABITUAL  REGURGITATION. 

In  this  neurosis  of  the  stomach  food  constantly  regurgitates 
into  the  mouth  during  the  course  of  digestion,  and  is  either 
expectorated  or  swallowed  again  according  to  circumstances. 
The  complaint  is  almost  entirely  confined  to  hysterical  and 
neurotic  persons,  and  affects  both  sexes.  In  many  instances 
there  is  a  history  of  excessive  masturbation  commencing  at 
an  early  period  of  life,  and  in  such  the  first  symptoms  usually 
occur  about  the  age  of  puberty.  In  others  the  disorder  appears 
to  follow  an  attack  of  influenza  or  diphtheria  or  even  acute 
pleurisy,  while  in  not  a  few  it  is  associated  with  some  other 
nervous  affection  of  the  stomach  and  forms  a  prelude  to  an 
access  of  nervous  vomiting.  Occasionally  the  habit  is  induced 
in  the  first  instance  by  pressure  upon  the  epigastrium  or  a 
voluntary  contraction  of  the  abdominal  muscles,  the  increase 
of  intragastric  pressure  brought  about  in  these  ways  being 
sufficient  to  express  a  portion  of  the  chyme  through  the  weak 
cardiac  sphincter  into  the  oesophagus.  Subsequently  the 
habit  becomes  involuntary  and  the  patient  is  no  longer  able  to 
control  the  regurgitation. 

In  a  well-developed  case  the  symptom  commences  within 


240  HABITUAL   REGURGITATION. 

half  an  hour  of  a  meal  by  the  regurgitation  of  a  small  quantity 
of  the  gastric  contents  into  the  mouth  every  few  minutes, 
preceded  on  each  occasion  by  a  slight  expiratory  effort  with 
the  glottis  closed  and  a  spasmodic  contraction  of  the  abdominal 
muscles.  The  material  is  always  liquid  in  character,  although 
it  contains  numerous  particles  of  food  and  its  taste  varies^ 
according  to  the  period  of  digestion,  being  insipid  in  the  first 
instance,  but  subsequently  becoming  more  and  more  acid. 
In  the  latter  condition  the  oesophagus  is  irritated  by  the 
gastric  juice  and  a  scalding  sensation  is  experienced  behind  the 
sternum  with  a  sour  taste  in  the  mouth.  Whenever  it  is 
possible  the  patient  spits  out  the  mouthful  of  food,  and  even 
when  circumstances  forbid  this  he  never  attempts  to  chew  it 
again  or  swallows  it  with  relish.  This  fact  forms  the  main 
distinction  between  habitual  regurgitation  and  rumination. 
The  symptom  gradually  subsides  as  the  stomach  becomes 
empty,  but  recurs  again  after  each  subsequent  meal.  It  is 
rarely  associated  either  with  nausea  or  flatulence.  Owing  to 
the  fact  that  only  a  small  quantity  of  the  ingesta  is  got  rid 
of  in  this  manner,  the  complaint  produces  no  deleterious  effect 
upon  the  general  nutrition,  and  it  is  only  in  exceptional  cases 
that  it  is  severe  enough  to  induce  progressive  loss  of  flesh. 
On  the  other  hand,  the  constant  annoyance  which  it  involves 
renders  the  subjects  of  the  complaint  extremely  depressed, 
nervous  and  irritable,  and  the  disorder  is  not  infrequently 
followed  by  hysteria,  neurasthenia,  nervous  vomiting,  or  by 
neurasthenia  gastrica.  There  is  no  evidence  that  it  ever 
leads  to  genuine  rumination. 

The  diagnosis  of  the  disorder  is  extremely  simple.  The 
involuntary  nature  of  the  regurgitation,  the  non-existence  of 
nausea,  flatulence,  and  other  symptoms  of  dyspepsia  serve  to 
distinguish  it  from  ordinary  pyrosis,  while  the  fact  that  the 
food  is  mixed  with  gastric  juice  and  only  regurgitates  after 
it  has  been  swallowed  for  some  time  negatives  the  possibility 
of  an  oesophageal  stricture.     An  oesophageal  pouch  also  gives 


TREATMENT.  24I 

rise  to  the  regurgitation  of  food,  but  in  this  condition  the 
material  contains  no  hydrochloric  acid,  is  semisolid  rather  than 
liquid,  and  often  exhibits  signs  of  putrefaction.  The  pas- 
sage of  a  tube  will  at  once  demonstrate  the  presence  of  a 
diverticulum. 

Treatment. — This  is  usually  disappointing.  In  every  case 
the  patient  should  be  made  to  eat  slowly,  to  masticate  the 
food  well,  and  to  avoid  any  form  of  pressure  upon  the  abdomen. 
Voluntary  efforts  to  suppress  the  regurgitation  are  always 
attended  by  a  certain  degree  of  success  and  should  be  en- 
couraged as  much  as  possible.  Occasionally  the  swallowing 
of  small  pieces  of  ice  is  said  to  reduce  the  frequency  of  the 
regurgitation.  The  application  of  electricity,  both  internally 
and  externally,  should  be  tried,  and  strychnine  and  other 
remedies  may  be  prescribed.  A  milk  diet  and  daily  massage 
often  reduce  the  severity  of  the  symptom,  but  when  the  patient 
returns  to  his  ordinary  mode  of  life  it  usually  recurs. 


16 


CHAPTER  VI. 
DYSPEPSIA  DUE  TO  DISPLACEMENTS  OF  THE  STOMACH. 

(Gastroptosis.) 

Anatomical  Considerations. — The  stomach  is  situated 
in  the  upper  part  of  the  abdominal  cavity  and  to  the  left  side. 
Above  it  are  the  diaphragm  and  the  liver;  below  it  is  the  trans- 
verse colon.  In  the  healthy  adult  its  extreme  length  is  about 
12  inches  and  its  width  about  4^  inches.  The  cardiac  ori- 
fice is  situated  i  inch  below  the  diaphragm  on  a  level  with 
the  ninth  dorsal  spine,  and  corresponds  in  front  to  the  seventh 
left  costal  cartilage  i  inch  distant  from  the  sternum.  The 
pylorus  lies  at  a  lower  level  and  is  nearer  the  surface.  Post- 
eriorly, it  is  on  a  level  with  the  twelfth  dorsal  spine,  while  in 
front  its  position  may  be  designated  by  the  point  of  intersection 
of  a  line  connecting  the  bony  ends  of  the  seventh  ribs  with 
one  drawn  parallel  to  and  midway  between  the  median  Hne 
of  the  sternum  and  the  right  border  of  that  bone.  The  fundus 
reaches  as  high  as  the  sixth  chondro-sternal  articulation  on 
the  left  side,  being  a  little  above  and  behind  the  apex  of 
the  heart.  The  lesser  curvature  runs  obliquely  downward  and 
to  the  right  under  cover  of  the  hver,  and  corresponds  post- 
eriorly to  the  upper  border  of  the  first  lumbar  vertebra.  The 
lower  border  is  extremely  variable  in  position,  but  when  the 
stomach  is  empty  it  may  be  denoted  roughly  by  a  line  drawn 
across  the  abdomen  between  the  bony  extremities  of  the  eighth 
ribs.  The  cardiac  orifice  is  the  most  fixed  part  of  the  organ, 
being  maintained  in  position  by  the  oesophagus  and  the  gastro- 
phrenic ligament.  In  addition  to  these  attachments,  the 
stomach  is  suspended  from  the  liver  by  the  gastro-hepatic 

242 


UPWARD   DISPLACEMENT.  243 

omentum,  and  is  securely  fixed  on  the  left  side  by  the  folds  of 
peritoneum  which  connect  it  with  the  spleen.  Below,  it  rests 
upon  a  cushion  of  intestines,  and  is  supported  in  front  by  the 
liver  and  abdominal  wall.  The  pylorus  is  the  most  movable 
part  of  the  viscus,  and  has  no  special  ligament,  so  that  when 
displaced  downward  it  is  chiefly  held  in  check  by  the  second 
portion  of  the  duodenum,  which  is  firmly  adherent  to  the 
posterior  abdominal  wall. 

The  stomach  may  undergo  displacement  upward,  laterally, 
or  downward. 

I.  UPWARD  DISPLACEMENT. 

This  can  only  occur  on  the  left  side,  since  on  the  other  the 
firm  and  fixed  liver  is  interposed  between  the  organ  and  the 
diaphragm.  It  is  met  with  in  all  conditions  that  tend  to 
shorten  the  vertical  diameter  of  the  thorax,  and  is  therefore  a 
common  result  of  the  atelectasis  that  ensues  from  a  left 
pleuritic  effusion  or  empyema,  and  of  chronic  interstitial 
inflammation  of  the  left  lung.  Large  ovarian  tumours,  uter- 
ine fibroids,  hydronephrosis  on  the  left  side,  meteorismus, 
and  ascites,  all  tend  to  push  the  stomach  into  the  left  con- 
cavity of  the  diaphragm,  and  the  same  condition  ensues  dur- 
ing the  later  months  of  pregnancy.  An  important  predisposing 
cause  of  this  form  of  displacement  is  to  be  found  in  that 
maldevelopment  of  the  thorax  which  gives  rise  to  an  ab- 
normally narrow  costal  arch.  In  cases  of  this  description, 
the  pressure  exercised  by  corsets  or  tight  clothes  tends  to  force 
the  lower  four  or  five  ribs  inward,  and  to  depress  the  line  of 
the  waist  until  it  may  reach  the  level  of  the  iliac  crests,  while 
at  the  same  time  the  colon,  stomach,  and  liver  are  pushed 
upward.  The  effect  upon  the  stomach  of  upward  dislocation 
varies  in  different  cases,  in  some  the  total  capacity  of  the  organ 
being  reduced,  while  in  others  the  pyloric  portion  becomes 
diminished  in  size  and  the  fundus  dilated.  Occasionally  the 
cardiac  region  is  pushed  upward  so  forcibly  that  the  lower 


244  UPWARD   DISPLACEMENT. 

end  of  the  oesophagus  is  bent  to  the  left  and.  the  lumen  of  the 
fundus  greatly  reduced.  In  rare  instances  the  whole  or  greater 
portion  of  the  stomach  gains  an  entrance  to  the  left  pleura 
through  a  rupture  of  the  left  wing  of  the  diaphragm,  and 
the  upper  and  left  parts  of  the  abdominal  ca\'ity  are  entirely 
occupied  by  intestine. 

Symptoms. — Upward  displacement  of  the  stomach  is 
rarely  accompanied  by  special  symptoms  unless  the  degree 
of  dislocation  is  considerable.  In  most  instances  discomfort 
and  fulness  are  experienced  after  meals,  attended  perhaps  by 
nausea,  flatulence,  and  palpitation.  In  more  pronounced  cases 
the  torsion  of  the  oesophagus  and  compression  of  the  fundus 
prevent  eructation  of  gas  and  vomiting,  so  that  the  feeling  of 
oppression  after  food  is  greatly  exaggerated,  and  the  patient 
is  unable  to  assume  a  recumbent  posture  without  experiencing 
an  alarming  sense  of  suffocation.  Upward  displacement  of  a 
distended  fundus  is  apt  to  induce  paroxysmal  attacks  of  dysp- 
noea and  palpitation  during  the  period  of  gastric  digestion, 
accompanied  by  giddiness,  cyanosis,  preecordial  pain,  and 
great  irregularity  of  the  pulse.  These  symptoms  are  always 
most  severe  after  the  evening  meal,  and  in  cases  of  weak  or 
diseased  heart  are  apt  to  occasion  severe  or  even  fatal  syncope. 
When  the  displacement  arises  from  narrowing  of  the  thorax 
and  the  creation  of  a  low  and  long  waist,  the  hepatic  and  splenic 
flexures  of  the  colon  are  forced  inward  and  backward,  and 
the  transverse  portion  of  the  bowel  is  not  infrequently  bent 
into  the  form  of  a  V  with  the  apex  pointing  toward  and 
reaching  within  a  few  inches  of  the  pubes.  These  changes 
in  the  position  of  the  colon  are  productive  of  muscular  in- 
sufficiency and  encourage  stagnation  and  fermentation  of 
its  contents,  which  in  their  turn  may  lead  to  chronic  colitis. 

Physical  Signs. — Artificial  inflation  of  the  stomach  shows 
that  the  fundus  reaches  an  abnormally  high  level  in  the  chest 
and  causes  displacement  of  the  apex  of  the  heart  to  the  right. 
Splashing  sounds  are  obtained  with  difficulty,  and  the  great 


TREATMENT.  245 

curvature  may  lie  so  much  above  its  usual  position  as  to  give 
the  impression  that  the  stomach  is  unduly  small. 

Treatment. — Care  must  be  taken  to  correct  as  far  as 
possible  the  conditions  which  are  responsible  for  the  abnormal 
position  of  the  stomach.  In  the  case  of  abdominal  tumours 
or  ascites,  the  removal  of  the  growth  or  the  fluid  is  at  once 
followed  by  a  descent  of  the  organ,  while  in  cases  of  meteorismus 
the  exhibition  of  suitable  aperients,  the  prohibition  of  green 
vegetables  and  fruit  and  a  course  of  intestinal  antiseptics, 
are  usually  followed  by  improvement.  When  the  distention 
results  from  chronic  intestinal  obstruction,  the  patient  should 
be  given  a  dose  of  castor  oil  each  morning  before  breakfast, 
pending  the  performance  of  an  operation.  In  those  cases 
where  the  malposition  depends  upon  an  abnormal  shape  of 
the  thorax,  the  wearing  of  tight  corsets  and  of  strings  round 
the  waist  should  be  avoided  as  far  as  possible,  and  the  patient 
should  be  taught  some  form  of  breathing  exercise  that  helps 
to  augment  the  capacity  of  the  chest.  Gymnastic  exercises 
which  promote  the  muscular  development  of  the  thorax  and 
trunk  are  also  of  benefit. 

Starch  and  sugars  should  only  be  allowed  in  moderation, 
and  care  should  be  taken  to  avoid  any  excess  of  fluid  with  the 
meals.  Effervescent  drinks  are  almost  always  harmful. 
Green  vegetables  should  be  taken  sparingly,  and  the  food 
must  be  thoroughly  masticated.  A  dose  of  cascara,  combined 
with  euonymin  and  rhubarb,  forms  an  excellent  corrective  of 
the  constipation,  but  sahnes  should  be  given  with  caution. 
When  much  respiratory  or  cardiac  distress  is  experienced  after 
meals,  a  carminative  and  antispasmodic  mixture  may  be  pre- 
scribed; and,  in  the  event  of  a  severe  attack,  the  patient  should 
pass  a  soft  tube  into  the  stomach  with  the  view  of  evacuating 
the  gas  which  cannot  escape  through  the  displaced  oesophagus. 
Intestinal  fermentation  may  be  corrected  by  means  of  cyllin, 
guaiacol,  or  salicylate  of  bismuth  taken  after  meals. 


246 


VERTICAL   DISPLACEMENT. 
II.  VERTICAL  DISPLACEMENT. 


In  this  variety  the  cardiac  orifice  and  the  fundus  retain 
their  normal  position,  but  the  lesser  curvature  and  pylorus  are 
displaced  dovioiward  and  inward  so  that  the  long  axis  of  the 
organ  tends  to  become  parallel  to  the  spine.  Three  anatomical 
forms  have  been  described — the  angular,  the  fish-hook,  and  the 
straight. 


Fig.  I. — "Angular"  displacement. 

(a)  In  the  angular  form,  which  is  by  far  the  most  common 
(Fig.  i),  the  pylorus  is  displaced  downward,  and  is  usually 
situated  in  the  median  line  of  the  abdomen  just  above  the 
umbilicus.  The  lower  half  of  the  lesser  curvature  runs  trans- 
versely across  the  abdomen  below  the  anterior  border  of  the 
liver,  while  the  upper  part  is  more  vertical  than  usual.  The 
fundus  reaches  the  fifth  or  sixth  interspace,  but  the  main  bulk 
of  the  stomach  is  located  in  the  left  hypochondrium  and  in  the 
left  side  of  the  abdominal  cavity. 


VERTICAL    DISPLACEMENT. 


247 


(b)  The  fish-hook  variety  (Fig.  2)  is  less  common  but  much 
more  important  than  the  preceding  one.  The  pylorus  main- 
tains its  normal  position,  but  its  orifice  is  directed  upward. 
From  this  point  the  pyloric  portion  of  the  viscus  runs  vertically 
downward  to  the  head  of  the  pancreas,  and  lies  parallel  and 
contiguous  to  the  second  part  of  the  duodenum.  The  lesser 
curvature  lies  below  the  liver  and  the  left  half  of  the  pancreas. 
The  cardiac  pouch  is  often  dilated,  and  the  great  curvature 


Fig.  2. — "Fish-hook"  stomach. 

may  extend  to  the  right  of  the  median  line  of  the  abdomen. 
The  acute  angle  formed  at  the  junction  of  the  first  and  second 
parts  of  the  duodenum  causes  the  stomach  to  act  at  a  dis- 
advantage, with  the  result  that  dilatation  of  the  viscus  often 
ensues,  while  its  muscular  insufficiency  becomes  further 
increased  by  the  drag  of  the  enlarged  organ  upon  the  fixed  part 
of  the  duodenum. 

(c)  The  straight  variety  (Fig.  3)  is  rare.     In  this  form  the 
pylorus  is  situated  at  or  below  the  level  of  the  umbilicus,  and  its 


248 


VERTICAL  DISPLACEMENT. 


changes  of  position  are  accompanied  by  much  stretching  of  the 
duodeno-hepatic  hgament.  The  stomach  becomes  elongated 
and  its  diameter  diminished,  while  its  long  axis  tends  to 
assume  a  vertical  direction.  The  liver  is  rotated  backward, 
and  is  often  laterally  compressed;  the  right  kidney  is  loose,  the 
spleen  is  depressed  and  deformed,  and  not  infrequently  the 
other  abdominal  viscera  undergo  a  downward  dislocation. 


Fig.  3. — "Straight"  vertical  displacement. 


Causation. — ^Vertical  displacement  of  the  stomach  is  very 
rare  in  men,  but  is  not  infrequent  in  women.  The  conditions 
which  favour  its  development  are  (i)  severe  pressure  ex- 
ercised upon  the  organ  by  the  liver  and  spleen,  owing  to  a 
natural  or  artificial  constriction  of  the  chest,  and  (2)  extreme 
laxity  of  the  abdominal  parietes.  According  to  Chapotot 
and  other  French  authorities,  the  principal  cause  of  the  thoracic 
deformity  is  the  use  of  a  tight  corset  during  the  period  of 
puberty,  which  tends  to  narrow  all  the  diameters  of  the  upper 


CAUSATION.  249 

portion  of  the  abdominal  cavity  and  to  prevent  their  develop- 
ment during  the  growth  of  the  body.  The  line  of  pressure 
extends  from  the  sixth  to  the  tenth  ribs,  and  divides  the  thorax 
into  two  cones,  which  have  their  apices  at  the  waist  line. 
The  liver,  being  composed  of  a  dense  tissue,  is  often  grooved 
across  its  anterior  surface  at  the  level  of  the  ensiform  cartilage, 
and  tends  to  press  the  pylorus  and  lesser  curvature  downward 
and  inward  in  the  direction  of  least  resistance.  On  the 
opposite  side  the  line  of  constriction  crosses  the  stomach  below 
the  fundus,  with  the  result  that  the  cardiac  portion  of  the 
viscus  is  forced  upward  while  the  rest  is  pushed  downward 
and  compressed  by  the  spleen.  In  this  manner  the  organ  is 
sometimes  moulded  into  two  sacs,  which  are  superimposed 
one  upon  the  other.  This  form  of  dislocation  is  greatly 
favoured  by  the  lax  condition  of  the  abdominal  wall  that  results 
from  repeated  pregnancies,  or  by  attenuation  of  the  tissues  in 
emaciated  persons.  All  enlargements  of  the  liver  tend  to  press 
the  stomach  downward  and  inward,  and  if  the  spleen  is  also 
increased  in  size  the  stomach  may  be  so  squeezed  between  these 
two  solid  organs  that  it  not  only  assumes  a  vertical  position, 
but  becomes  so  diminished  in  transverse  diameter  as  to  closely 
resemble  a  piece  of  large  intestine  (Kussmaul,  Bouveret). 
In  this  country,  where  tight  corsets  are  less  in  favour  than  in 
France  and  are  rarely  worn  by  young  girls,  the  dislocation  of 
the  stomach  more  often  depends  upon  some  malformation  of 
the  thorax  or  upon  arrested  development  of  the  organ  itself. 
The  rickety  chest,  which  presents  much  narrowing  of  its 
transverse  diameter  with  eversion  of  the  costal  margins,  is 
almost  always  associated  with  downward  dislocation  of  the 
liver  and  pylorus,  while  in  many  cases  of  lateral  curvature  of 
the  spine  depression  of  the  liver  and  diaphragm  give  rise  to  a 
vertical  displacement  of  the  stomach.  Members  of  phthisical 
families  who  possess  long  narrow  chests  are  also  unduly  prone 
to  suffer  from  a  vertical  stomach  during  adult  life,  the  abnor- 
mally short  diameters  of  the  lower  thorax  in  such  persons 


250  VERTICAL   DISPLACEMENT. 

giving  rise  to  a  permanent  depression  of  the  liver,  and  thus 
producing  a  similar  effect  to  the  corset  chest.  It  is  also 
possible,  as  Kussmaul  suggested,  that  in  certain  cases  a 
vertical  stomach  may  result  from  want  of  development,  since  it 
is  known  that  during  foetal  life  the  long  axis  of  the  organ  is 
almost  parallel  to  the  spine. 

Symptoms. — During  the  early  'stages  of  the  complaint, 
and  in  many  cases  throughout  life,  the  patient  seems  to  be 
in  no  way  inconvenienced  by  the  abnormal  position  of 
her  stomach;  but,  as  a  rule,  the  condition  is  associated  with 
definite  symptoms  of  disordered  digestion,  and  may  even  be 
responsible  for  a  permanent  state  of  ill-health.  The  chief 
troubles  are  experienced  when  the  motility  of  the  stomach 
becomes  affected.  The  acute  angle  formed  at  the  junction 
of  the  first  and  second  portions  of  the  duodenum  renders  the 
passage  of  chyme  into  the  intestine  a  matter  of  considerable 
difficulty,  and  this  mechanical  obstruction  becomes  gradually 
intensified  as  the  progressive  enlargement  of  the  stomach 
exercises  an  ever-increasing  traction  upon  the  fixed  point. 
Under  these  circumstances,  a  sense  of  discomfort,  fulness,  or 
oppression  is  experienced  immediately  after  each  meal,  accom- 
panied by  flushing  of  the  face  and  ears,  palpitation  and  giddi- 
ness, while  occasionally  the  peristaltic  movements  of  the  stom- 
ach give  rise  to  severe  pain  of  a  cramping  character,  followed, 
perhaps,  by  vomiting.  That  the  abnormal  position  of  the  organ 
is  the  cause  of  these  symptoms  is  shown  by  the  fact  that  they 
are  always  relieved  when  the  patient  assumes  a  recumbent  pos- 
ture, and  can  be  almost  entirely  prevented  by  the  application 
of  a  firm  binder  to  the  abdomen  so  as  to  support  the  stomach 
and  diminish  the  traction  upon  the  duodenum.  When  mus- 
cular insufficiency  ensues  from  the  vertical  displacement,  secon- 
dary gastritis  is  apt  to  supervene  and  to  obscure  the  symptoms  of 
the  original  disorder.  In  this  condition  the  ingestion  of  food  is 
followed  within  a  short  time  by  pain,  distention,  and  flatu- 
lence, and  in  many  instances  by  acid  eructations  and  vomiting. 


SYMPTOMS.  251 

Constipation  is  invariably  present,  and  in  some  instances  an 
intractable  form  of  mucous  colitis  complicates  the  gastric 
derangement.  Sooner  or  later  emaciation  accompanied  by 
anaemia  supervenes,  and  the  patient  finds  herself  unable  to 
indulge  in  physical  exercise  without  suffering  from  dragging 
pains  in  the  abdomen  and  profound  exhaustion.  She  is  also 
prone  to  become  morose,  irritable,  and  melancholic,  and  not 
infrequently  exhibits  a  strong  tendency  to  hypochondriasis. 
One  of  the  peculiarities  of  the  ansemia  and  its  attendant  debil- 
ity is  that  while  they  remain  unaffected  by  the  administration 
of  iron  or  arsenic,  they  rapidly  respond  to  rest  in  bed  and  care- 
ful dieting.  A  peculiar  and  distressing  symptom  which  is 
exhibited  by  many  women  who  suffer  from  vertical  dislocation 
of  the  stomach  is  a  loud  gurgling  noise  that  accompanies  the 
respiratory  movements  whenever  the  organ  is  filled  with  food. 
In  such  cases  the  act  of  inspiration  is  attended  by  a  splashing 
sound  in  the  abdomen,  while  during  expiration  a  series  of 
gurghngs  become  audible  and  may  be  heard  at  a  distance  of 
several  yards.  These  noises  become  intensified  if  the  patient 
yawns,  coughs,  or  sneezes,  but  can  be  suppressed  by  loosening 
the  corset,  lying  upon  the  back,  or  by  pressure  applied  to  the 
abdomen  with  the  object  of  pushing  the  stomach  toward  the 
diaphragm.  Striimpell  believed  that  the  sounds  were  indica- 
tive of  a  dilated  stomach,  but  Glozier  has  shown  that  this  con- 
dition is  not  necessary  to  their  production.  It  would  appear 
that  the  phenomenon  is  due  to  the  partial  constriction  of  the 
stomach  aforementioned,  which  gives  rise  to  the  formation  of 
two  pouches  superimposed  one  upon  the  other.  The  move- 
ments of  the  diaphragm  and  the  abdominal  wall  during  res- 
piration cause  the  fluid  present  in  the  organ  to  regurgitate  in 
a  rhythmical  manner  from  one  sac  into  the  other,  and  a  splash 
is  produced  at  each  collision  between  the  liquid  and  gaseous 
contents  of  the  viscus.  Occasionally  the  duodenum  is  dragged 
down  to  such  an  extent  by  the  enlarged  and  dislocated  stom- 
ach that  the  opening  of  the  bile  duct  becomes  situated  in 


252  VERTICAL   DISPLACEMENT. 

the  angle  between  the  two  hmbs  of  the  intestine  (Fig.  2).  In 
such  cases  bile  is  apt  to  trickle  constantly  into  the  stomach 
and  to  be  vomited  at  intervals  (Malbranc,  Riegel),  as  much  as 
3  pints  being  sometimes  ejected  during  the  course  of  the 
day  (Weill).  An  excess  of  bile  in  the  stomach  is  known  to 
inhibit  the  action  of  pepsin  (Bernard,  Liiber),  and  it  has  there- 
fore been  surmised  that  the  emaciation  which  always  accom- 
panies this  abnormal  symptom  is  the  direct  result  of  dis- 
ordered digestion.  It  is  more  probable,  however,  that  the  loss 
of  bile  to  the  system  is  the  principal  cause  of  the  loss  of  flesh, 
since  the  establishment  of  a  biliary  fistula  in  animals  is  always 
followed  by  emaciation.  In  addition  to  the  characteristic 
bilious  vomiting,  the  patient  almost  invariably  suffers  from 
flatulence,  loss  of  appetite,  distention  after  meals>  and  a  con- 
stant feeling  of  nausea. 

Physical  Signs. — The  abnormal  appearance  of  the  chest 
will  usually  suggest  the  possibility  of  dislocation  of  the  stomach. 
In  the  majority  of  the  cases  the  thorax  is  long  and  narrow, 
with  a  contraction  of  its  lower  aperture.  The  angle  formed 
by  the  margins  of  the  ribs  on  either  side  is  much  smaller  than 
normal,  and  the  costal  borders  may  be  almost  parallel,  and 
only  separated  from  one  another  by  2  or  3  inches.  When  the 
deformity  is  due  to  tight  lacing,  a  transverse  furrow  exists 
between  the  sixth  and  ninth  ribs  and  the  lower  aperture  of  the 
thorax  appears  somewhat  expanded  owing  to  eversion  of  the 
costal  arch.  On  inspection,  the  epigastric  region  is  unduly 
flat,  while  the  left  hypochondriac,  umbilical,  and  left  lumbar 
regions  are  more  prominent  than  usual  and  give  the  abdomen 
an  unequal  or  lopsided  appearance.  If  the  stomach  be  artifi- 
cially inflated,  it  will  be  observed  that  the  epigastrium  remains 
unaffected,  while  the  protuberance  of  the  umbihcal  region  and 
left  hypochondrium  is  increased.  On  percussion  the  fundus 
of  the  stomach  is  found  to  occupy  its  normal  position,  and  its 
upper  border  may  reach  as  high  as  the  fifth  left  interspace. 
The  great  curvature  lies  for  the  most  part  under  cover  of  the 


DIAGNOSIS  AND   PROGNOSIS.  253 

ribs,  but  emerges  near  the  tip  of  the  tenth  rib,  and  runs  thence 
across  the  abdomen  toward  the  pylorus,  which  is  usually- 
situated  in  the  vicinity  of  the  umbiHcus.  In  the  median  hne, 
only  the  left  lobe  of  the  liver  and  the  pancreas  intervene  between 
the  abdominal  wall  and  the  spine,  and  here  forcible  pulsations 
of  the  aorta  may  be  both  seen  and  felt. 

In  about  one-half  of  the  cases  a  moderate  degree  of  hyper- 
acidity accompanies  the  dislocation  of  the  stomach,  but  this 
abnormal  state  of  the  gastric  juice  rarely  gives  rise  to  any 
special  symptoms.  Dilatation  of  the  organ  is  usually  followed 
by  a  diminution  of  the  secretion,  and  when  secondary  gastritis 
supervenes,  subacidity  is  an  invariable  feature  of  the  case. 
When  gastric  displacement  is  accompanied  by  enteroptosis, 
the  right  kidney  is  loose,  the  liver  extends  2  or  3  inches  below 
the  costal  margin  and  is  unduly  movable,  and  the  hepatic 
flexure  of  the  colon  undergoes  prolapse. 

Diagnosis  and  Prognosis. — Vertical  dislocation  of  the 
stomach  is  usually  confused  with  dilatation,  but  with  a  little 
care  the  two  conditions  may  easily  be  distinguished  from  one 
another.  In  gastrectasis  the  capacity  of  the  organ  is  greatly 
increased,  the  fundus  is  dragged  down  and  occupies  the  lower 
part  of  the  epigastric,  the  umbilical  and  perhaps  the  hypogas- 
tric region,  the  pylorus  usually  retains  its  normal  position,  and 
the  passage  of  a  tube  will  show  that  the  viscus  contains  food 
seven  hours  after  a  moderate  meal.  On  the  other  hand,  in 
vertical  displacement,  the  fundus  usually  reaches  the  fifth  inter- 
space on  the  left  side,  the  lesser  curvature  lies  below  the  liver, 
the  pylorus  is  encountered  near  the  median  line  of  the  abdo- 
men, and  no  evidence  of  food  retention  can  be  detected  by  the 
use  of  the  tube. 

When  painful  peristalsis  arises  from  traction  upon  the  duo- 
denum, the  case  may  be  mistaken  for  one  of  hyperacidity  or 
hypersecretion.  Careful  examination  of  the  abdomen,  how- 
ever, will  at  once  indicate  that  the  stomach  occupies  an 
abnormal  position,  while  exploration  of  the  organ  will  prove 


254  VERTICAL  DISPLACEMENT. 

that  the  gastric  secretion  is  neither  sufl&ciently  acid  nor  abun- 
dant to  afford  an  adequate  explanation  of  the  symptoms. 

Vertical  displacement,  if  uncomplicated  by  motor  in- 
sufficiency, does  not  possess  much  clinical  importance;  but  if  it 
gives  rise  to  gastric  dilatation,  chronic  gastritis,  or  mucous 
colitis,  it  may  initiate  a  state  of  permanent  ill-health,  accom- 
panied by  the  symptoms  that  are  characteristic  of  these 
several  complaints.  The  regurgitation  of  bile  is  a  matter  of 
considerable  moment,  and  unless  carefully  treated  may  give 
rise  to  fatal  inanition. 

Treatment. — The  main  indications  are  to  prevent  further 
displacement  of  the  stomach,  to  support  the  organ,  and  to 
correct  any  secondary  disturbances  of  digestion  that  may 
occur.  Tight  corsets  must  always  be  avoided,  especially  in  girls 
who  possess  a  long  narrow  chest  and  come  of  a  phthisical  stock. 
In  such  cases  the  corset  should  either  be  short  and  loose, 
or  be  replaced  by  a  band  of  some  warm  firm  material.  Ex- 
ercises undertaken  with  the  view  of  strengthening  the  muscles 
of  the  arms,  chest,  and  abdomen  are  extremely  valuable,  and 
the  patient  should  be  taught  to  inspire  deeply  through  the 
nose,  so  as  to  increase  the  capacity  of  the  thorax.  In  every 
instance,  a  firm,  well-fitting  belt  should  be  applied  to  the 
abdomen,  in  such  a  way  as  to  elevate  and  sustain  the  stomach. 
The  belt  should  be  applied  in  the  recumbent  posture,  and  be 
worn  both  night  and  day. 

When  anaemia  and  emaciation  are  prominent  features  of 
the  case,  rest  in  bed  is  essential  and  should  be  maintained 
for  a  month  or  six  weeks.  Abdominal  massage  and  electricity 
are  useful  adjuncts  in  some  cases.  The  salts  of  iron  rarely 
agree,  but  arsenic,  nux  vomica,  and  gentian  are  of  value,  and 
a  dose  of  hydrochloric  acid  administered  after  meals  is  an 
important  aid  to  digestion  when  the  gastric  secretion  is 
diminished.  Regurgitation  of  bile  should  be  treated  by  lavage 
at  night,  while  a  full  dose  of  sulphate  of  sodium  is  given  in 
hot  water  at  an  early  hour  every  morning.     Should  these 


FREUQENCY.  255 

means  prove  ineffectual  in  relieving  the  bilious  vomiting,  it 
may  be  necessary  to  invoke  surgical  aid  with  the  view  of 
stitching  the  lesser  curvature  to  the  under  surface  of  the  liver. 

III.  TOTAL  DESCENT  OF  THE  STOMACH  (GASTROPTOSIS). 

Gastroptosis  is  by  far  the  most  frequent  form  of  displace- 
ment, and  is  usually  associated  with  dislocation  of  other 
abdominal  viscera.  It  is  characterised  by  a  descent  of  the 
entire  stomach,  the  cardiac  orifice  being  dragged  down  to  the 
level  of  the  twelfth  dorsal  vertebra,  while  the  great  curvature 
may  reach  any  point  between  the  navel  and  the  symphysis 
pubis.  The  chief  distinction  between  this  condition  and 
dilatation  of  the  stomach  is  that  in  the  former  the  distance 
between  the  upper  and  lower  margins  of  the  organ  remains 
the  same  as  in  the  normal  state,  while  in  cases  of  gastrectasis 
the  apparent  breadth  of  the  viscus  is  greatly  increased. 

Frequency. — The  recognition  of  the  slighter  degrees  of 
gastroptosis  being  attended  by  considerable  difficulty,  it  is 
almost  impossible  to  determine  the  absolute  frequency  with 
which  the  displacement  occurs.  Meinert  examined  fifty  girls 
of  twelve  years  of  age,  and  found  evidence  of  gastric  displace- 
ment in  nearly  one-half  of  them,  while  among  his  adult  female 
patients  some  anomaly  in  the  position  of  the  stomach  existed 
in  80  per  cent.  According  to  this  observer,  a  similar  condition 
only  occurs  in  about  5  per  cent,  of  the  male  population. 

Among  patients  suffering  from  diseases  other  than  those 
affecting  the  digestive  organs,  I  found  gastroptosis  in  6  per 
cent,  of  the  males  and  in  t,^  per  cent,  of  the  females. 

With  regard  to  the  frequency  of  gastroptosis  among  persons 
who  suffer  from  functional  disorders  of  digestion,  Einhorn 
detected  its  existence  in  6 . 2  per  cent,  of  his  male  and  in  34 . 8 
per  cent,  of  his  female  patients.  Out  of  500  consecutive  cases 
of  dyspepsia  which  came  under  my  notice  at  the  London 
Temperance  Hospital,  the  digestive  disturbance  was  dependent 
upon  gastroptosis  in  3  per  cent.,  while  in  a  similar  series  occur- 


256  TOTAL   DESCENT    OF   THE    STOMACH. 

ring  in  private  practice  the  percentage  was  17.6.  In  both 
classes  the  ratio  of  females  to  males  was  about  4  to  i.  It 
may  therefore  be  accepted  that  in  about  5  per  cent,  of  all 
cases  of  indigestion  the  symptoms  will  be  found  to  depend 
upon  a  downward  displacement  of  the  stomach  or  those 
morbid  conditions  which  ensue  from  it. 

Causation. — Several  conditions  seem  to  predispose  to  the 
development  of  gastroptosis.  Families  which  possess  a  strong 
tendency  to  tuberculosis  are  unduly  prone  to  suffer  from  the 
complaint,  owing  possibly  to  their  possession  of  abnormally 
long  and  narrow  chests,  with  a  contraction  of  the  lower 
aperture.  The  displacement  is  also  exceptionally  frequent  in 
persons  who  have  suffered  from  tuberculosis  of  the  lung  in 
early  life,  but  have  made  a  complete  recovery.  In  both 
these  cases  the  displacement  is  usually  associated  with  neu- 
rasthenia gastrica,  and  the  resultant  symptoms  are  exceedingly 
intractable  to  treatment.  Certain  congenital  anomalies  of 
the  peritoneal  folds  which  support  the  stomach,  such  as  an 
abnormal  length  of  the  gastro-hepatic,  duodeno-hepatic,  and 
gastro-phrenic  hgaments,  or  an  extreme  tenuity  of  their  struc- 
ture, hkewise  predispose  to  downward  displacement  of  the 
viscus,  the  degree  of  which  increases  when  the  body  has 
attained  its  full  development.  In  many  instances  of  this 
description  the  floating  tenth  rib,  to  which  Stiller  has  drawn 
attention,  is  found  to  exist. 

Gastroptosis  may  be  acquired  in  a  variety  of  ways:  (i) 
All  forms  of  dilatation  of  the  stomach  are  accompanied  by  a 
downward  dislocation  of  the  viscus  as  a  result  of  its  increased 
weight,  and  consequently  gastroptosis  is  invariably  met  with  in 
cicatricial  and  other  chronic  forms  of  obstruction  of  the  pylorus 
or  duodenum,  as  well  as  in  severe  cases  of  myasthenia  gastrica. 
(2)  Extensive  emphysema  of  the  lungs,  especially  if  it  be 
associated  with  som-e  deformity  of  the  chest  or  spine,  always 
gives  rise  to  a  flattening  of  the  diaphragm  and  downward  dis- 
placement of  the  abdominal  organs  that  lie  in  contact  with  it, 


CAUSATION.  257 

and  for  a  similar  reason  pleuritic  effusion  or  pneumothorax 
affecting  the  left  side  of  the  chest  is  accompanied  temporarily 
by  dislocation  of  the  stomach.  (3)  Attenuation  and  stretching 
of  the  abdominal  wall,  associated  with  a  diminution  of  intra- 
abdominal pressure,  are  potent  causes  of  displacement  of  the 
abdominal  organs,  and  the  latter  condition  is  therefore  fre- 
quently encountered  in  emaciated  persons  whose  lying-in 
periods  have  been  unduly  curtailed  or  from  whom  ascitic  fluid 
or  a  large  tumour  of  the  uterus  or  ovary  has  been  removed. 
(4)  Certain  specific  fevers,  such  as  typhoid,  influenza,  and 
pneumonia,  are  apt  to  produce  great  enfeeblement  of  the 
gastrointestinal  tract,  which  becomes  evident  during  the 
period  of  convalescence.  In  the  case  of  enteric  fever,  the 
resultant  gastroptosis  is  greatly  increased  by  excessive  feeding 
after  the  subsidence  of  the  pyrexia  and  the  presence  of  an 
enlarged  and  fatty  liver.  (5)  General  neurasthenia  is  always 
accompanied  by  a  relaxation  of  the  gastric  ligaments,  and  for  a 
similar  reason  the  majority  of  the  cases  of  neurasthenia 
gastrica  are  accompanied  by  gastroptosis.  It  is  also  interesting 
to  note  that  the  complaint  is  unduly  frequent  in  women  who  are 
the  subjects  of  mitral  stenosis,  and  that  the  removal  of  the 
ovaries  before  the  age  of  thirty  is  very  apt  to  be  followed  by 
displacement  of  the  stomach  and  other  viscera.  The  same 
result  is  occasionally  observed  in  neurotic  individuals  who  have 
undergone  laparotomy  for  other  conditions.  (6)  Most  writers 
lay  stress  upon  the  influence  of  a  tight  corset  in  the  production 
of  gastroptosis,  and  there  can  be  no  doubt  that  the  com- 
pression of  the  chest  which  is  thus  brought  about  hinders  the 
development  of  the  thorax  and  forces  the  abdominal  viscera 
downward.  In  England  tight  lacing  is  comparatively  infre- 
quent and  only  existed  in  about  4  per  cent,  of  the  cases  of 
gastroptosis  that  have  come  under  my  notice.  (7)  In  rare 
instances,  inflammatory  shortening  of  the  great  omentum 
drags  the  great  curvature  of  the  stomach  downward,  and 
causes  much  displacement  of  the  viscus.  In  one  of  my  cases 
17 


258  TOTAL  DESCENT  OF   THE   STOMACH. 

the  omentum  was  represented  by  two  fibrous  cords,  which 
v/ere  fixed  at  their  lower  extremities  to  the  wall  of  the  pelvis 
and  had  dragged  the  stomach  into  the  umbilical  region; 
while  in  another  it  formed  a  tight  sheet,  which  was  adherent  on 
either  side  to  Poupart's  ligament,  and  had  not  only  displaced 
the  stomach  and  colon,  but  had  also  compressed  the  small 
intestines  against  the  spine. 

Symptoms. — Gastroptosis  is  a  condition  that  is  extremely 
variable  in  its  clinical  expression.  In  many  instances,  probably 
in  the  majority,  it  remains  latent  throughout  the  greater  part  of 
life,  and  it  may  only  be  as  the  result  of  a  severe  illness  or 
physical  shock  that  the  characteristic  symptoms  are  called  into 
being.  This  latency  is  particularly  common  in  men,  and  Bial 
has  estimated  that  only  about  one-half  of  the  male  subjects  of 
gastroptosis  suffer  any  inconvenience  from  the  condition. 
The  clinical  picture  which  it  presents  also  varies  considerably 
according  to  its  mode  of  causation,  the  nervous  constitution  of 
the  patient,  and  the  existence  of  complications;  so  that  in  many 
cases  it  is  difficult  to  determine  whether  the  gastroptosis  is 
the  primary  affection  or  is  merely  a  result  of  the  coexisting 
neurasthenia  or  gastrectasis.  But  however  complicated  the 
case  may  appear,  certain  symptoms  usually  exist  which  prove 
sufficiently  striking  to  direct  attention  to  the  possibility  of  a 
primary  visceral  displacement.  In  the  first  place,  the  abdom- 
inal phenomena  prove  remarkably  intractable  to  ordinary 
methods  of  treatment,  and  even  when  they  partially  subside 
their  place  is  usually  taken  by  others  arising  from  neurasthenia 
or  gastric  myasthenia.  Secondly,  the  patient  is  very  susceptible 
to  psychical  impressions,  and  immediately  suffers  from  a 
recrudescence  of  the  former  troubles  if  exposed  to  mental 
or  physical  overstrain  or  if  she  exhibits  an  emotional  outburst. 
Thirdly,  there  usually  exists  a  degree  of  general  debihty  for 
which  the  most  careful  examination  fails  to  detect  an  adequate 
cause,  and  even  the  effort  of  walking  or  sitting  erect  in  a  chair 
will  often  induce  a  sense  of  weakness  in  the  back,  accompanied 


SYMPTOMS.  259 

by  dragging  sensations  in  the  hypogastrium  and  groins. 
Lastly,  all  these  symptoms  are  rapidly  relieved  when  the 
patient  is  confined  to  bed  or  a  comfortable  support  is  applied 
to  the  abdomen  in  such  a  way  as  to  elevate  and  hold  up  the 
dislocated  viscera. 

A  careful  consideration  of  the  numerous  cases  of  gastro- 
ptosis  that  have  come  under  my  care  has  convinced  me  that, 
although  the  symptoms  vary  greatly  in  their  nature  and 
severity  under  different  conditions,  there  is  a  general  tendency 
for  certain  phenomena  to  group  themselves  together  in  such 
a  manner  that  the  complaint  presents  a  series  of  chnical 
pictures  in  which  minor  or  secondary  symptoms  form  an  ever- 
changing  background.  Of  these,  three  principal  forms  may 
be  recognised,  the  first  of  which  ischaracterised  by  the  promin- 
ence of  certain  gastric  troubles;  the  second  by  periodical 
attacks  of  headache  and  vomiting,  very  similar  to  those  of 
migraine;  while  in  the  third  variety  profound  exhaustion  is 
associated  with  angemia  and  emaciation,  and  with  vague  pains 
in  the  abdomen  and  back. 

(i)  The  Dyspeptic  Form. — This  is  by  far  the  most  common 
and  is  met  with  in  both  sexes.  It  is  especially  frequent  in  those 
who  come  of  a  tuberculous  stock  or  who  have  suffered  from 
tuberculosis  in  early  life.  The  degree  of  gastroptosis  is 
usually  moderate  and  is  accompanied  by  looseness  of  the  right 
kidney  and  some  prolapse  of  the  hepatic  flexure  of  the  colon. 
Occasionally  several  members  of  a  family  suffer  in  a  similar 
manner  after  attaining  the  age  of  puberty.  It  is  important 
to  observe  that  psychical  impressions  exert  a  most  important 
influence  upon  the  course  and  severity  of  the  complaint  and 
that  a  strong  emotion,  such  as  fear,  anxiety,  or  worry,  will 
always  excite  an  attack  within  the  course  of  a  few  hours.  In 
severe  instances  the  symptoms  may  continue  with  occasional 
remissions  for  many  months,  but  in  milder  cases  they  only 
manifest  themselves  at  intervals.  Sleep,  though  sound,  is 
usually  unrefreshing,  and  the  patient  suffers  from  abdominal 


26o  TOTAL   DESCENT    OF   THE    STOMACH. 

distention  and  flatulent  eructations  as  soon  as  she  rises  from 
bed.  Less  frequently,  colicky  pains  are  experienced  in  the  left 
side  of  the  abdomen,  and  several  ineffectual  attempts  may  be 
made  to  relieve  the  bowels  before  breakfast.  Whatever  be  the 
constitution  of  a  meal,  oppression  at  the  chest  and  distention 
ensue  soon  after  its  ingestion,  accompanied  perhaps  by  flushing 
of  the  face,  pressure  at  the  praecordium,  and  palpitation. 
Within  a  short  time  noisy  eructations  occur  and  large  quan- 
tities of  an  odourless  and  tasteless  gas  are  belched  up.  When 
the  symptoms  are  persistent,  the  eructation  usually  lasts  for 
about  an  hour,  but  during  an  acute  attack  it  may  continue  with 
shght  remissions  for  thirty-six  hours  or  even  longer.  Some- 
times the  effort  to  expel  the  gas  from  the  stomach  produces 
violent  retching  and  headache,  but  vomiting  is  rarely  observed. 
After  an  attack  has  subsided  the  whole  of  the  abdomen  feels 
sore  and  tender  to  the  touch  for  several  days. 

The  bowels  are  usually  confined,  but  the  patient  may 
prove  extremely  susceptible  to  purgative  medicines,  and  even  a 
minute  dose  of  calomel  will  often  set  up  troublesome  diarrhoea. 
Although  there  may  be  no  actual  loss  of  weight,  the  patient 
remains  thin  and  ill-nourished,  and  often  fails  to  put  on  flesh 
even  when  subjected  to  the  most  careful  feeding.  When 
pregnancy  occurs,  excessive  flatulence  gives  rise  to  great  dis- 
comfort, and  after  parturition  a  severe  attack  of  distention  and 
eructation  almost  invariably  ensues. 

(2)  The  Bilious  Form. — The  symptoms  which  characterise 
this  variety  are  far  more  often  met  with  in  women  than  in  men, 
and  usually  develop  between  the  agefe  of  twenty-four  and  forty. 
As  a  rule,  there  is  a  history  of  a  similar  complaint  in  other 
members  of  the  family,  especially  on  the  maternal  side,  and  as  a 
child  the  patient  may  have  suffered  from  severe  bilious  attacks. 
The  complaint  usually  manifests  itself  for  the  first  time  after  a 
period  of  general  ill  health,  but  it  may  develop  suddenly  after 
an  attack  of  enteric  fever,  influenza,  or  diarrhea.  At  first 
the  symptoms  recur  at  regular  intervals,  but  with  the  progress 


SYMPTOMS.  261 

of  time  they  tend  to  become  more  and  more  frequent,  until 
only  a  few  days  may  intervene  between  the  attacks.  Some- 
times a  sense  of  fulness  in  the  abdomen  in  the  early  morning, 
accompanied  by  pressure  in  the  head  or  giddiness,  betrays 
the  imminence  of  a  seizure,  but  as  a  rule  it  develops  quite 
suddenly  about  10  a.m.  or  5  p.m.,  and  may  even  be  preceded 
by  a  feeling  of  exceptional  well-being.  Women  are  very 
hable  to  suffer  either  immediately  before  or  after  the  menstrual 
periods.  The  first  symptom  to  appear  is  headache,  which 
affects  the  whole  vault  of  the  cranium  and  is  often  associated 
with  pain  or  pressure  behind  the  eyes;  but  the  ocular  phe- 
nomena that  occur  in  migraine  are  never  encountered.  The 
pain  rapidly  increases  in  intensity,  and  is  exaggerated  by  any 
movement  of  the  head,  stooping,  or  coughing,  but  is  relieved 
by  a  recumbent  posture.  Within  a  short  time  nausea  super- 
venes, and  finally  vomiting  occurs.  Temporary  relief  follows 
the  evacuation  of  the  stomach,  but  the  headache  and  other 
symptoms  soon  return,  and  violent  attacks  of  retching  recur 
at  short  intervals.  At  first  the  ejecta  consist  entirely  of  semi- 
digested  food  mixed  with  a  large  quantity  of  hyperacid  gastric 
juice;  but  subsequently  they  acquire  an  alkaline  reaction,  and 
are  found  to  be  composed  entirely  of  bile  and  mucus.  In  some 
of  my  cases  the  vomit  consisted  of  gastric  juice,  and  the  whole 
course  of  the  disorder  closely  resembled  that  of  acute  hyper- 
secretion. During  the  attack  the  appetite  remains  in  abeyance, 
and  any  attempt  to  relieve  the  thirst  is  followed  by  sickness. 
The  pulse  is  small  and  slow,  the  temperature  of  the  body 
subnormal,  and  the  urine  is  diminished  in  quantity  and  alkaline 
in  reaction.  Unlike  migraine,  sleep  is  not  followed  by  relief 
of  the  symptoms,  and  both  the  headache  and  vomiting  usually 
continue  during  the  course  of  the  following  day.  Great  debility 
and  mental  depression  are  experienced  after  an  attack,  and 
the  patient  usually  loses  from  2  to  5  lbs.  in  weight  during  its 
continuance.  In  the  intervals  a  certain  amount  of  flatu- 
lence and  acidity  are  experienced  after  meals,  and  there  is  a 


262  TOTAL  DESCENT  OF  THE  STOMACH. 

tendency  to  constipation,  while  examination  of  the  stomach 
almost  invariably  proves  the  existence  of  chronic  hyperacidity. 
(3)  The  Asthenic  Form. — In  this  variety  there  is  a  complaint 
of  persistent  weakness,  mental  depression,  and  vague  pains  in 
the  abdomen  and  back.  Both  sexes  are  affected,  but  it  is 
especially  common  in  women  who  have  bom  several  children 
in  quick  succession  and  have  bestowed  little  care  upon  them- 
selves during  the  lying-in  period.  Anaemia  is  always  present, 
and  gives  rise  to  dyspnoea  on  exertion,  palpitation,  giddiness, 
and  occasionally  to  oedema  of  the  feet,  while  examination  of 
of  the  blood  shows  a  moderate  diminution  both  of  red  cor- 
puscles and  haemoglobin.  The  appetite  is  poor  and  capricious, 
and  the  ingestion  of  any  form  of  food  is  usually  followed  by 
discomfort,  distention,  and  flatulence.  Want  of  energy  and 
physical  weakness  are  very  pronounced  and  ate  sometimes 
so  severe  as  to  render  the  patient  a  complete  invalid.  Very 
slight  exertion  induces  exhaustion,  and  any  attempt  at  physical 
exercise  is  followed  by  complete  prostration.  There  is  also 
great  difl&culty  of  mental  concentration,  and  many  persons 
complain  bitterly  of  the  fact  that  they  are  unable  to  add  up 
figures,  to  keep  accounts,  or  even  to  read  a  newspaper.  Head- 
ache is  a  variable  symptom,  and  when  it  exists  is  chiefly  felt 
in  the  early  morning  or  before  meals.  Walking  or  even 
sitting  upright  in  a  chair  is  accompanied  by  uneasy  sensations 
in  the  back  and  by  vague  pains  in  the  lower  abdomen,  while 
in  many  cases  the  patient  experiences  a  curious  feeling  of 
emptiness  in  the  epigastrium  and  the  contents  of  the  abdomen 
seem  as  though  they  were  "faUing  out."  The  bowels  are 
always  constipated,  and  not  infrequently  the  administration 
of  an  aperient  is  followed  by  partial  collapse.  These  varied 
sensations  are  always  relieved  when  the  recumbent  posture 
is  assumed,  and  the  comfort  that  is  experienced  by  remain- 
ing in  bed  probably  accounts  for  the  habits  of  invalidism 
which  are  exhibited  by  so  many  sufferers  from  gastroptosis. 
Splashing    and    gurgling    during   respiration,    like   that   met 


PHYSICAL    SIGNS.  263 

with  in  vertical  displacements  of  the  stomach,  are  frequently 
present. 

Loss  of  flesh  is  a  prominent  and  disturbing  feature  of 
gastroptosis,  and  the  emaciation  may  attain  the  same  degree 
as  that  met  with  in  diabetes  or  carcinoma  of  the  stomach. 
It  is  usually  found,  however,  that  the  loss  of  weight  is  very 
irregular,  sometimes  amounting  to  i  or  2  lb.  a  week,  while 
at  others  it  remains  stationary  for  several  weeks  in  succession. 
The  first  indication  of  a  restoration  to  health  consists  in  a 
deposition  of  fat  in  the  mammary  region  and  an  increase  of 
elasticity  of  the  skin,  after  which  the  body  weight  undergoes 
steady  augmentation.  Most  patients  complain  of  constantly 
feeling  chilly,  despite  the  excess  of  clothing  which  they  affect, 
and  inspection  of  the  extremities  shows  that  the  hands,  feet, 
nose,  and  ears  are  cold  and  clammy  and  present  a  bluish 
colour.  It  is  also  noticeable  that  a  northerly  or  easterly  wind 
is  invariably  accompanied  by  an  exacerbation  of  all  the 
symptoms,  and  that  a  cold  or  bracing  climate  produces  a 
most  injurious  effect  upon  them. 

Physical  Signs. — Inspection  of  the  abdomen  during  the 
period  of  digestion  affords  important  indications  of  gastro- 
ptosis. Thus  in  many  cases  the  normal  protuberance  of  the 
epigastrium  is  seen  to  be  replaced  by  a  hollow  or  transverse 
furrow,  while  the  umbilical  and  hypogastric  regions  are 
more  prominent  than  usual.  Occasionally  a  practised  eye 
will  be  able  to  discern  the  outline  of  the  stomach  through 
the  abdominal  wall,  and  if  gastrectasis  comphcates  the  dis- 
location, the  peristaltic  movements  of  the  organ  may  also  be 
visible.  Percussion  of  the  stomach  alone  is  valueless,  and 
the  mere  determination  of  the  position  of  the  great  curvature 
not  only  fails  to  indicate  the  location  of  the  viscus,  but  often 
leads  to  an  erroneous  diagnosis  of  gastrectasis.  Even  Leube's 
method  of  percussing  the  stomach  after  the  introduction  of 
water,  with  the  patient  in  the  erect  position,  fails  to  delineate 
the  lesser  curvature;  and  since  the  determination  of  the  upper 


264  TOTAL   DESCENT    OF    THE    STOMACH. 

border  of  the  stomach   is   all-important  in   the   recognition 
of  gastroptosis,  it  is  necessary  to  employ  some  other  pro- 
cedure, such    as    auscultatory-percussion,   artificial  inflation, 
or  electric  transillumination  which  will  furnish  the  requisite  . 
information. 

Auscultatory-percussion  is  performed  in  the  following 
manner:  Half  a  pint  or  more  of  effervescent  soda-water  is 
administered  to  the  patient  with  the  view  of  procuring  moderate 
distention  of  the  stomach,  and  he  is  then  directed  to  he  upon 
his  back  with  the  shoulders  and  head  slightly  raised.  The 
examiner  places  the  end  of  a  stethoscope  over  the  epigastrium 
and  then  makes  a  series  of  short  taps  with  the  index  finger 
of  the  right  hand  upon  the  abdominal  wall  along  lines  that 
radiate  from  the  point  of  auscultation.  As  long  as  percussion 
is  made  over  a  spot  where  the  stomach  is  in  contact  with  the 
parietes  of  the  abdomen,  the  shock  conveyed  to  the  ear  remains 
of  the  same  intensity;  but  immediately  the  finger  travels  off 
the  gastric  area  the  sound  becomes  faint  and  toneless.  The 
points  at  which  this  change  occurs  are  marked  on  the  skin 
with  a  blue  pencil,  and  the  investigation  is  continued  in  all 
directions  until  the  entire  outline  of  the  viscus  is  mapped  out 
upon  the  surface  of  the  abdomen.  This  method  is  not  only 
very  accurate  in  its  results,  but  is  also  easy  of  performance 
and  does  not  entail  any  discomfort  to  the  patient.  The  only 
point  which  requires  special  attention  is  the  application  of 
the  stethoscope  immediately  over  the  stomach. 

Artificial  inflation  of  the  stomach  may  be  performed  in 
two  ways:  either  by  the  administration  of  chemical  substances 
which  generate  carbonic  acid  gas  when  mixed  together  or  by 
forcibly  pumping  air  into  the  organ.  Inflation  by  carbon 
dioxide  is  a  very  old  procedure  (Wagner,  1869),  which  has 
recently  been  brought  into  fashion  by  Riegel  and  Boas. 
About  60  grains  of  bicarbonate  of  sodium  and  40  grains  of 
tartaric  acid  are  each  dissolved  in  8  oz.  of  water  contained 
in  separate  glasses.     The  patient  first  drinks  the  acid  and 


PHYSICAL    SIGNS.  265 

then  the  alkahne  solution  and  is  directed  not  to  eructate  any 
gas.  The  interaction  of  the  two  substances  causes  a  rapid 
evolution  of  gas,  which  distends  the  stomach  and  causes  its 
outlines  to  become  visible  through  the  abdominal  parietes. 
In  the  second  method,  a  soft  tube  is  introduced  into  the 
stomach,  and  air  is  either  pumped  in  through  a  hand-bellows 
or  blown  in  by  the  mouth  until  the  organ  is  sufficiently  dis- 
tended to  be  visible.  Hemmeter  prefers  a  rubber  bag  made 
in  the  shape  of  the  stomach,  which  is  introduced  in  the  end  of 
a  soft  tube  and  can  be  inflated  in  position.  The  disadvantages 
of  artificial  inflation  are  that  it  entails  a  certain  amount  of 
discomfort,  and,  unless  carefully  performed,  may  seriously 
embarrass  the  action  of  the  heart;  while,  by  distending  the 
stomach  to  its  utmost  capacity,  it  is  apt  to  produce  an  ex- 
aggerated conception  of  the  size  of  the  organ  and  the  degree 
of  downward  displacement. 

Gastrodiaphany,  or  electric  transillumination,  is  a  favourite 
method  with  some  Continental  and  American  physicians,  who 
assert  that  its  employment  serves  not  only  to  establish  the 
diagnosis  of  gastroptosis,  but  also  to  differentiate  it  from  gas- 
trectasis.  That  the  method  is  capable  of  affording  important 
evidence  concerning  the  position  of  the  stomach  has  been 
proved  beyond  doubt,  but  that  it  is  either  necessary  or  even  con- 
venient to  employ  it  is  extremely  doubtful.  For  my  own  part,  I 
only  use  it  for  the  purposes  of  clinical  demonstration,  as  I  have 
found  that  in  private  practice  the  apparatus  is  so  cumbersome 
and  the  passage  of  the  tube  so  obnoxious  to  patients  that  the 
results  obtained  from  it  are  rarely  commensurate  with  its  disad- 
vantages. Whatever  method  be  employed,  it  is  always  advis- 
able to  mark  the  outlines  of  the  stomach  upon  the  skin  of  the 
abdomen  with  a  coloured  pencil,  so  that  the  relation  of  the  two 
curvatures  may  be  brought  into  prominent  relief.  When  this 
is  done,  it  will  be  observed  that,  while  the  normal  distance 
between  them  is  preserved,  the  upper  border  of  the  stomach 
lies  well  below  the  edge  of  the  liver  and  the  great  curvature 


266  TOTAL  DESCENT  OF  THE   STOMACH. 

crosses  the  abdomen  at  some  point  between  the  umbiHcus  and 
the  symphysis. 

Percussion  over  the  space  between  the  liver  and  the  stomach 
affords  a  dull  note,  and  the  semilunar  area  of  Traube  fails  to 
afford  the  tympanitic  resonance  characteristic  of  the  stomach. 
Palpation  along  and  above  the  upper  border  of  the  organ  is 
almost  always  painful,  and  there  often  exists  a  circumscribed 
tender  area  in  the  epigastrium  similar  to  that  met  with  in  cases 
of  gastric  ulcer,  while  the  left  lobe  of  the  liver  and  cartilages 
on  the  left  side  are  also  abnormally  sensitive.  In  some  in- 
stances the  pancreas  can  be  felt  as  a  hard  and  somewhat  tender 
mass,  lying  across  the  spine  above  the  stomach,  and  occasion- 
ally the  gland  exhibits  distinct  pulsation  owing  to  the  proximity 
of  the  aorta.  These  signs  are  due  to  the  uncovering  of  the 
deeper  structures  of  the  abdomen  by  the  downward  displace- 
ment of  the  stomach,  and  are  often  mistaken  for  evidences  of 
abdominal  tumour,  ulcer,  or  aneurysm. 

The  prolapsed  stomach  does  not  move  as  readily  on  respira- 
tion as  it  does  in  its  normal  position,  and  firm  pressure  by  the 
hand  will  often  prevent  its  ascent  toward  the  thorax  during 
expiration.  Its  degree  of  lateral  mobility  is  also  a  notable 
feature,  and  when  the  \iscus  is  partiaUy  fiUed  with  food  it  can 
sometimes  be  grasped  between  the  hands  and  pushed  about 
in  all  directions  in  the  abdominal  cavity.  Examination  of  the 
contents  of  the  stomach  does  not  afford  any  characteristic 
signs.  In  about  one-half  of  the  cases  hyperacidity  is  found  to 
exist;  but  when  gastrectasis  occurs,  the  excess  of  hydrochloric 
acid  usuaUy  disappears  or  is  replaced  by  subacidity. 

Complications. — Pronounced  gastroptosis  is  extremely  apt 
to  give  rise  to  motor  insufficiency,  owing  to  the  acute  flexure 
of  the  upper  part  of  the  duodenum  which  so  often  occurs.  In 
such  cases  symptoms  of  stagnation  and  fermentation  of  the  food 
gradually  manifest  themselves,  and  the  patient  suffers  an  access 
of  pain  about  an  hour  after  each  meal,  accompanied  by  flatu- 
lence, acidity,  nausea,  and  occasionally  by  vomiting.     As  a 


DIAGNOSIS.  267 

rule,  however,  the  expulsion  of  gas  from  the  stomach  is  more 
difficult  than  under  normal  conditions,  and  vomiting  is  only 
accompHshed  with  much  straining  and  in  the  recumbent 
posture.  Loss  of  flesh  is  invariable,  and  the  emaciation  may 
become  so  severe  as  to  suggest  serious  organic  mischief.  The 
effort  of  the  stomach  to  force  its  contents  into  the  intestine 
gradually  produces  hypertrophy  of  its  muscular  coat,  and 
finally  leads  to  dilatation  of  its  cavity.  It  is  for  this  reason 
that  long-standing  cases  of  gastroptosis  are  so  frequently 
accompanied  by  signs  of  myasthenia  and  gastrectasis.  The 
secondary  fermentations  of  the  food  that  ensue  from  these 
conditions  are  apt  to  excite  chronic  inflammation  of  the  gas- 
tric mucous  membrane,  which  in  its  turn  intensifies  the  sensa- 
tions of  discomfort  after  meals,  destroys  the  appetite,  and 
leads  to  rapid  emaciation.  Finally,  the  continued  entrance 
into  the  bowel  of  food  in  an  undigested  and  fermenting 
condition  disturbs  the  processes  of  intestinal  digestion  and 
excites  inflammation  of  the  colon,  which  manifests  itself 
by  attacks  of  griping  pain  in  the  abdomen  and  mucous  diar- 
rhoea. Chronic  pharyngitis,  undue  susceptibility  to  cold,  and 
deficient  circulation  in  the  extremities  are  also  frequently 
associated  with  these  digestive  disorders.  In  the  present  state 
of  our  knowledge  it  is  difficult  to  say  whether  the  neurasthenic 
and  hysterical  symptoms  so  often  displayed  by  the  subjects 
of  gastroptosis  are  the  result  of  the  gastric  displacement  or 
of  independent  origin,  but  there  can  be  no  doubt  that  the 
deterioration  of  the  general  health,  which  the  dislocation  of 
the  stomach  and  its  sequelae  so  often  produce,  tends  materially 
to  depress  the  nervous  system  and  to  exaggerate  the  symptoms 
that  arise  from  its  functional  derangement. 

Lastly,  the  stomach  may  become  twisted  upon  its  axis,  with 
the  formation  of  a  kind  of  volvulus.  Of  this  rare  condition 
Wiesinger  has  reported  an  instance,  and  Beck  has  successfully 
operated  upon  two  cases  of  a  similar  nature. 

Diagnosis. — The   clinical   history   of   the   case   will  often 


268  TOTAL    DESCENT    OF    THE    STOMACH. 

indicate  the  probable  existence  of  gastroptosis.  Thus,  if  a 
Vi^oman  who  has  borne  several  children,  who  has  undergone 
an  abdominal  operation,  or  has  suffered  for  a  length  of  time 
from  general  debility  complains  of  flatulence  and  pain  after 
meals  which  no  ordinary  treatment  appears  capable  of  curing, 
suffers  from  attacks  of  headache  and  vomiting  at  irregular 
intervals,  or  complains  of  extreme  weakness,  loss  of  flesh,  and 
vague  abdominal  pains  when  in  the  erect  position,  especial 
care  should  be  taken  to  ascertain  the  exact  location  of  the 
stomach  and  the  manner  in  which  it  performs  its  various  func- 
tions. On  the  other  hand,  a  diagnosis  of  displacement  can 
only  be  made  by  the  discovery  of  the  malposition  of  the  stomach 
on  physical  examination.  In  true  gastroptosis  the  entire  organ 
is  found  to  have  been  dislocated  downward  in  the  abdominal 
cavity,  the  lesser  curvature  lying  below  the  liver  and  the  great 
curvature  considerably  below  the  level  of  the  umbilicus.  The 
region  usually  occupied  by  the  viscus  is  dull  on  percussion,  and 
both  the  pancreas  and  the  pulsations  of  the  aorta  may  be 
detected  on  palpation  above  its  upper  margin. 

The  effects  of  treatment  are  also  confirmatory  of  the  diagno- 
sis, since  under  ordinary  circumstances  Httle  or  no  improve- 
ment follows  the  adoption  of  measures  which  prove  effectual 
in  other  varieties  of  dyspepsia,  while  rest  in  bed  and  the  use  of 
an  abdominal  support  afford  immediate  relief. 

Gastroptosis  is  often  confounded  with  dilatation  of  the 
stomach,  and  although  the  two  conditions  frequently  coexist, 
it  is  imperative  that  they  should  be  carefully  distinguished 
from  each  other.  A  dilated  stomach  always  occupies  a  lower 
position  in  the  abdomen  than  normal,  owing  to  the  drag  exer- 
cised upon  its  ligaments  by  its  increased  weight.  It  may  be 
observed,  however,  that  the  organ  is  greatly  increased  in  bulk 
when  dilated,  and  hence  the  distance  between  the  two  curva- 
tures is  much  augmented.  In  many  instances  also  the  peris- 
taltic movements  of  the  viscus  are  plainly  visible  through  the 
abdominal  wall,  vomiting  occurs  at  intervals,  and  the  passage 


TREATMENT.  269 

of  a  tube  proves  the  existence  of  food  retention;  while  a  chemical 
examination  of  the  gastric  contents,  combined  with  the  clinical 
history  of  the  complaint,  will  usually  indicate  the  cause  of  the 
pyloric  or  duodenal  stenosis. 

In  long-standing  cases  of  myasthenia,  the  stomach  under- 
goes a  certain  degree  of  dilatation  and  becom^es  consequently 
dragged  out  of  its  place.  Under  these  conditions  visible 
peristalsis  is  usually  absent,  vomiting  is  infrequent,  and  the 
evidence  of  food  stagnation  and  decomposition  is  less  marked 
than  in  pyloric  stenosis. 

When  gastroptosis  causes  kinking  of  the  duodenum  with 
secondary  enlargement  of  the  stomach,  the  condition  may  be 
difficult  to  distinguish  from  an  organic  stenosis  of  the  pylorus. 
In  most  instances,  however,  it  will  be  found  that  the  vomiting 
subsides  as  soon  as  the  patient  is  confined  to  bed,  that  hyper- 
acidity is  absent,  and  that  rapid  improvement  ensues  from  the 
use  of  a  well-fitting  belt. 

Prognosis.^ — Gastroptosis  is  rarely,  if  ever,  cured.  On  the 
other  hand,  careful  treatment  will  usually  reheve  the  symptoms, 
and  should  the  abdominal  walls  regain  their  tone  and  the 
internal  tension  be  permanently  increased,  the  condition  may 
cease  to  be  a  menace  to  health.  Gastrectasis  and  colitis  are 
serious  complications,  while  the  coexistence  of  neurasthenia 
or  hysteria  intensifies  the  general  symptoms  and  retards  recov- 
ery. Many  of  the  subjects  of  severe  gastroptosis  succumb 
eventually  to  tuberculosis. 

Treatment. — Much  may  be  accomplished  in  the  prevention 
of  gastroptosis  by  careful  attention  to  the  clothing  and  the  early 
correction  of  those  conditions  which  are  commonly  responsible 
for  its  development.  Young  girls  should  never  be  permitted 
to  wear  tight  corsets,  and  at  all  ages  tight  lacing  should  be  dis- 
couraged. For  a  similar  reason,  strings  and  bands  worn  round 
the  waist  should  be  avoided,  and  buttons  substituted  for 
them  when  possible.  During  the  lying-in  period,  special  atten- 
tion should  be  bestowed  upon  bandaging  the  abdomen,  so 


270  TOTAL   DESCENT   OF   THE   STOMACH. 

as  to  afford  a  firm  support  to  the  viscera  and  aid  the  belly  to 
regain  its  former  shape.  Any  attempt  subsequently  to  improve 
the  figure  by  tight  lacing  should  be  discouraged,  since  the  chief 
effect  of  the  corset  is  to  force  the  stomach  and  intestines 
downward,  while  it  fails  to  afford  any  support  to  the  parietes 
below  the  waist.  Care  should  also  be  taken  to  reduce  the 
gaseous  distention  of  the  bowels  that  usually  occurs  after 
delivery,  and  to  overcome  the  natural  tendency  to  constipation. 
The  patient  should  never  be  allowed  to  walk  before  the  tone 
of  the  abdominal  muscles  has  been  restored.  The  same  rules 
apply  to  persons  who  have  undergone  abdominal  operations, 
and  to  those  cases  in  particular  where  the  intra-abdominal 
tension  has  been  suddenly  lowered  by  the  removal  of  a  large 
tumour  or  an  excess  of  fluid.  The  treatment  of  the  dislocated 
stomach  itself  is  a  purely  mechanical  one.  In  mild  or  recent 
cases  confinement  to  bed  for  a  month  is  invaluable,  as  it  not 
only  tends  to  cut  short  the  progress  of  the  complaint,  but 
completely  reheves  the  symptoms  which  emanate  from  it. 

Rest  cures  also  act  advantageously,  since  the  patient  is 
forced  to  occupy  the  recumbent  position;  while  an  excess  of 
nourishment  leads  to  the  accumulation  of  fat  in  the  abdomen. 
Under  all  conditions,  persons  suffering  from  gastroptosis 
should  be  advised  to  lie  down  for  an  hour  after  meals,  and  at 
the  same  time  to  loosen  the  corsets  and  clothing  round  the 
waist.  By  this  simple  procedure  the  symptoms  that  ensue 
during  the  period  of  digestion  are  rendered  much  less  severe 
and  stagnation  of  the  food  is  to  a  great  extent  prevented. 

Lavage  is  of  no  value  unless  the  condition  is  complicated 
by  gastrectasis  or  chronic  gastritis,  nor  in  ordinary  cases  do 
massage  and  electricity  produce  any  direct  effect  upon  the 
stomach.  As  means,  however,  of  strengthening  the  muscles 
of  the  abdomen,  they  are  often  extremely  useful. 

The  essential  factor  in  the  treatment  is  the  application  of  a 
firm  belt  to  the  abdomen,  which  will  support  the  stomach  and 
hold  it  in  position.     Numerous  varieties  have  been  devised 


TREATMENT.  27I 

for  this  purpose  (Glenard,  Landau,  Bardenheuer,  Rosenheim, 
Teufel),  but  it  must  be  remembered  that  a  belt  that  suits  one 
person  will  not  necessarily  suit  another,  and  consequently  that 
no  stock  pattern  can  be  prescribed  without  pre\dous  trial. 
Many  of  the  corset-belts  now  in  fashion  either  exaggerate  all 
the  ill  effects  of  the  corset  or  afford  no  support  whatever  to  the 
prolapsed  stomach.  As  a  rule,  the  binder  or  belt  should  extend 
from  the  lower  border  of  the  twelfth  rib  to  the  symphysis,  and 
should  be  made  of  some  hght  but  firm  material,  which  will  not 
easily  stretch.  Silk  elastic  makes  an  excellent  belt,  but  it 
needs  constant  renewal.  The  support  should  be  applied  when 
lying  upon  the  back  and  should  be  laced  or  tightened  from 
below  upward.  To  prevent  it  from  riding  up,  a  perineal  band 
may  be  worn  or,  in  the  case  of  a  woman,  the  suspenders  may 
be  attached  to  it  on  either  side.  For  some  time  the  belt  must 
be  worn  both  day  and  night,  but  when  considerable  improve- 
ment has  taken  place  it  may  be  left  off  when  the  patient  goes  to 
bed. 

Surgical  Treatment. — Buret,  in  1894,  was  the  first  to  treat 
gastroptosis  by  an  operation,  which  consisted  of  suturing  the 
lesser  curvature  to  the  abdominal  wall,  while  three  years  later 
Davis  adopted  the  plan  of  fixing  the  lesser  omentum  to  the 
parietes.  Rovsing  attempted  to  suture  the  anterior  wall  of  the 
stomach,  and  Coffey  the  great  omentum  below  the  transverse 
colon,  to  the  parietes,  while  Beyea  and  Bier  introduced  methods 
of  plicating  and  shortening  the  gastro-phrenic  and  gastro- 
hepatic  hgaments.  More  recently  Eve  has  reported  a  case  in 
which  a  successful  result  was  attained  by  suturing  the  lesser 
curvature  of  the  stomach  to  the  liver.  Although  the  various 
cases  which  have  been  subjected  to  operation  are  reported  to 
have  improved,  I  cannot  help  feeling  that  most  cases  of  gastro- 
ptosis severe  enough  to  warrant  operation  are  of  too  com- 
plicated a  nature  to  promise  a  cure  from  mere  elevation  of  the 
stomach,  and  that  the  neurasthenia  which  invariably  exists  is  a 
more  important  factor  in  the  production  of  the  symptoms  than 


272  TOTAL  DESCENT  OF  THE  STOMACH. 

the  mere  dislocation  of  the  stomach.  When  the  gastric  dis- 
placement is  due  to  organic  stenosis  of  the  pylorus  or  duo- 
denum, gastroenterostomy  is  usually  sufficient  without 
suturing  the  stomach  to  the  liver  or  abdominal  wall.  Fixation 
of  the  right  kidney  has  no  effect  whatever  upon  a  coexisting 
dislocation  of  the  stomach,  and  usually  increases  the  gastric 
symptoms  by  the  induction  of  nervous  shock. 

Diet. — The  food  must  be  regulated  according  to  the 
necessities  of  each  case  and  the  existence  or  otherwise  of 
complications. 

Gastroptosis  associated  with  healthy  intestinal  functions 
and  good  gastric  compensation  merely  requires  a  full  diet 
composed  of  substances  that  are  easily  digested.  Moderately 
cooked  and  tender  meats,  fish,  game,  eggs,  sweetbread,  tripe, 
sheep's  head,  calf's  head  and  feet,  well-boiled  cereals,  far- 
inaceous puddings,  and  a  moderate  amount  of  fruit  may  be 
allowed;  and  the  patient  should  be  encouraged  to  drink  milk 
with  the  meals  and  to  indulge  in  cream  and  other  forms  of  fat. 
RavvT  vegetables,  pastry,  sauces,  pickles,  and  cheese  should  be 
avoided.  When  emaciation  is  a  marked  feature  of  the  case 
and  is  attended  by  neurasthenia,  a  milk  diet  is  often  of  great 
value,  5  pints  mixed  with  a  small  proportion  of  Hme-water 
being  administered  in  divided  doses  during  the  course  of  the 
day. 

Gastroptosis  accompanied  by  myasthenia  requires  a  diet 
suited  to  this  important  complication.  The  great  principles  to 
be  borne  in  mind  are  to  supply  the  stomach  with  those  forms 
of  food  which  are  most  easy  of  digestion,  to  avoid  over-dis- 
tention  of  the  organ,  and  to  allow  a  sufficient  interval  to  elapse 
between  the  meals  in  order  that  the  viscus  may  completely 
empty  itself  on  each  occasion. 

Sugars  and  fats  in  excess  are  always  injurious,  owing  to  the 
tendency  of  the  former  to  undergo  fermentation  and  of  the 
latter  to  stagnate  in  the  stomach.  Butter  and  cream  may  be 
allowed  in  moderation,  as  well  as  rice  and  well-cooked  oatmeal 


TREATMENT.  273 

porridge.  Lean  meats,  white  fish,  fowl,  game,  and  eggs  may 
be  given,  but  soups  and  broths  should  be  avoided.  Spinach 
and  asparagus  may  be  taken  in  small  quantities,  but  raw  and 
coarse  vegetables  are  difficult  of  digestion.  An  exclusive 
milk  diet  rarely  agrees,  owing  to  the  distention  of  the  stomach 
which  ensues  from  the  introduction  of  large  quantities  of  fluid, 
and  at  most  8  oz.  should  be  taken  with  each  meal.  Tea  and 
coffee  rarely  agree,  and  cocoa  proves  injurious  from  the  sugar 
it  contains.  A  decoction  of  cocoa  husks  or  cocoa  nibs  forms 
a  palatable  drink,  and  is  free  from  the  disadvantages  which 
pertain  to  the  other  varieties.  If  the  patient  is  accustomed  to 
take  alcohol,  a  little  good  brandy  or  whisky  may  be  allowed; 
but,  as  a  rule,  half  a  tumblerful  of  hot  water,  sipped  at  the  end 
of  the  meal,  is  more  beneficial. 

When  colitis  complicates  the  gastric  displacement,  the  diet 
should  consist  entirely  of  finely  minced  fish,  poultry,  tripe, 
sweetbreads,  and  sheep's  brains,  dry  toast,  meat  juices,  clear 
soup  without  vegetables,  potatoes,  and  plain  milk  puddings. 
Green  vegetables  and  fruits  are  particularly  harmful,  and,  as  a 
rule,  red  meats  should  be  avoided.  Vichy  or  Contrexeville 
water  may  be  taken  with  the  meals. 

Medicinal. — In  uncomplicated  cases  drugs  are  seldom  of 
much  value,  and  the  treatment  is  chiefly  symptomatic.  If  the 
appetite  is  bad,  a  dose  of  nitro-hydrochloric  or  phosphoric  acid, 
combined  with  a  bitter  infusion,  may  be  given  between  the 
meals.  Occasionally  the  sense  of  extreme  weakness  may 
require  the  exhibition  of  strychnine,  nux  vomica,  cinchona, 
or  some  other  tonic;  while  in  many  instances  cod-liver  oil,  the 
compound  syrup  of  the  hypophosphites,  elixir  of  phosphorus, 
or  formate  of  sodium,  produce  a  beneficial  influence  upon  the 
symptoms  of  neurasthenia.  Pain  after  food  and  flatulence 
usually  depend  upon  some  morbid  condition  of  the  gastric 
secretion  or  an  increased  sensibility  of  the  gastric  mucous 
membrane,  and  in  such  cases  the  compound  bismuth  mixture, 
with  or  without  morphine,  will  usually  afford  relief.     Some- 

i8 


274  TOTAL   DESCENT   OF   THE    STOMACH. 

times  a  preparation  of  pepsin  or  pancreatine,  or  the  tabloids 
of  peptenzyme,  appear  to  aid  the  processes  of  digestion.  The 
development  of  myasthenia  requires  the  addition  of  carbolic 
acid  to  the  bismuth  mixture,  while  in  cases  complicated  by 
colitis  full  doses  of  salicylate  of  bismuth,  cyllin,  or  guaiacol 
should  be  employed.  The  selection  of  a  suitable  aperient  is 
always  a  matter  of  importance.  As  a  rule,  severe  purgatives 
must  be  avoided,  and  reliance  be  placed  on  small  doses  of 
cascara  and  euonymin,  combined,  if  necessary,  with  belladonna 
and  rhubarb.  In  other  cases,  a  confection  of  cascara  and 
maltine,  taken  at  bedtime,  proves  efficient,  or  one  composed 
of  guaiacum,  senna,  and  ginger  may  be  employed  with  advan- 
tage. When  colitis  is  accompanied  by  constipation,  nothing 
is  so  effectual  as  a  small  dose  of  castor  oil  each  morning  before 
breakfast;  but  if  severe  neurasthenia  exists,  all  purgatives  may 
have  to  be  omitted,  and  a  daily  action  of  the  bowels  secured 
by  an  enema  of  soap  and  water.  Carlsbad  salts  and  other 
salines  are  chiefly  indicated  when  myasthenia  with  stagnation 
of  food  exists,  as  their  employment  effects  a  form  of  internal 
lavage,  and  the  fermenting  contents  of  the  stomach  are 
swept  into  the  intestine.  In  other  respects  the  medicinal 
treatment  of  gastroptosis  is  conducted  upon  the  lines  laid 
down  for  the  management  of  chronic  gastritis  and  atony  of 
the  stomach.     (Chap.  IV.) 


CHAPTER  VII. 

DYSPEPSIA    DUE    TO    THE     PRESENCE    OF    FOREIGN 
BODIES  AND  LIVING  CREATURES  IN  THE  STOMACH. 

Hair-balls,    Bezoars,     Gastroliths,    Larvae,    Beetles,    Slugs, 

Lizards,  etc. 

Symptoms  of  gastric  irritation  frequently  ensue  from  the 
presence  of  a  foreign  body  in  the  stomach.  It  is  well  known 
that  persons  of  unsound  mind  will  sometimes  swallow  sub- 
stances of  considerable  size  and  of  the  most  varied  nature, 
nails,  bandages,  knife-handles,  forks,  spoons,  pieces  of  glass, 
and  other  articles  of  hardware,  having  one  and  all  been  dis- 
covered in  the  digestive  organs  of  lunatics.  Children  and 
hysterical  individuals  are  also  apt  to  ingest  insoluble  substances 
which  give  rise  to  inflammation  of  the  stomach  and  intestines, 
while  occasionally  jugglers  undergo  the  unpleasant  experience 
of  being  unable  to  recover  the  swords  or  knives  which  they 
had  swallowed  for  the  amusement  of  their  audience.  In  almost 
all  these  cases,  however,  the  history  will  at  once  indicate  the 
origin  of  the  abdominal  trouble  and  the  Rontgen  rays  will 
demonstrate  the  nature  and  location  of  the  foreign  body. 
On  the  other  hand,  there  is  a  very  important  class  of  chronic 
dyspepsia  in  which  the  disorder  depends  either  upon  the 
gradual  formation  in  the  stomach  of  a  mass  of  hair,  cotton, 
or  vegetable  fibre,  the  constituent  threads  of  which  had  been 
swallowed  at  intervals  during  a  long  period  of  time,  or  of 
large  concretions  of  resin  that  had  been  introduced  into  the 
body  in  an  alcoholic  solution.  In  other  cases,  again,  the 
indigestion  is  due  to  the  presence  in  the  stomach  and  intestines 
of  a  vast  number  of  living  larvae  of  various  flies  and  beetles 
which  excite  a  severe  form  of  gastroenteritis  and  may  even 

275 


276  HAIR-BALLS  AND    OTHER   CONCRETIONS. 

multiply  within  their  host.    It  is  with  such  unusual  and  obscure 
causes  of  dyspepsia  that  the  present  chapter  is  concerned. 

(i)  HAIR-BALLS  AND  OTHER  CONCRETIONS. 

Hair-halls  of  sufficient  size  to  attract  attention  are  very 
rare,  and  I  have  been  able  to  collect  only  twenty-five  cases, 
the  first  of  which  was  recorded  by  Baudamant  in  1777.^ 
When  comparatively  small,  the  mass  is  round  or  oval  in  shape 
and  occupies  the  pyloric  region,  where  it  acts  like  a  ball- valve; 


Fig.  4. — A  hair-ball  (about  one-half  natural  size). 

but  as  it  increases  in  size  it  becomes  moulded  by  the  gastric 
contractions,  until  it  forms  a  solid  cast  of  the  organ,  and  may 
even  extend  upward  into  the  oesophagus  (Best)  or  through 
the  pylorus  into  the  jejunum  (Gull,  Pollock).  It  is  smooth 
on  the  surface,  compact  and  heavy,  and  consists  of  a  vast 
number  of  hairs,  varying  from  2  to  12  inches  in  length,  which 
are  closely  interwoven  and  agglutinated  by  mucus  and  food 
debris.  In  Gull's  case  the  component  hairs  were  of  three 
colours  and  could  be  recognised  as  belonging  to  the  patient 
and  her  two  children.     Sometimes  the  hair  is  mixed   with 

^  Schonborn  states  that  in  the  year  1883  only  seven  cases  had  been  recorded. 
He  appears,  however,  to  have  overlooked  English  and  American  literature. 


HAIR-BALLS   AND    OTHER    CONCRETIONS.  277 

cotton,  thread,  or  pieces  of  string.  The  largest  concretion  on 
record  weighed  4  lb.  7  oz.  (Russell)  and  the  smallest  5!  oz. 
The  habit  of  swallowing  hair  is  not  confined  to  the  human 
subject,  but  is  met  in  the  lower  animals,  and  especially  in 
cats,  the  Angora  breed  of  which  are  said  frequently  to  die  from 
gastric  concretions,  owing  to  their  habit  of  eating  their  fur 
when  it  is  shed  at  certain  periods  of  the  year  (Chepmell). 
Lunatics  usually  prefer  harder  substances,  such  as  nails  and 
crockery,  but  in  a  case  recorded  by  Quain  fatal  perforation 
of  the  stomach  was  caused  by  a  ball  of  cocoanut  fibre  weigh- 
ing 4  lb. 

Concretions  composed  of  vegetable  matter  are  occasionally 
found  in  the  stomachs  of  persons  who  have  consumed  large 
quantities  of  fibrous  roots  or  of  other  substances,  owing 
to  a  perverted  appetite  or  from  a  superstitious  belief  in  their 
medicinal  properties.  Thus,  in  Kooyker's  case  a  mass  of 
starch  and  vegetable  fibre  weighing  29  oz.  was  found  in  the 
stomach  after  death,  while  in  that  recorded  by  Schreiber  the 
organ  was  completely  filled  by  a  mass  of  roots  (Schwar2;wur2el). 

Stones  or  gastroliths  are  very  rare,  and  I  have  been  able 
to  find  only  four  authentic  cases  in  the  literature.  They 
usually  consist  of  shellac,  which  had  been  introduced  into  the 
stomach  in  the  form  of  an  alcoholic  polish  or  varnish,  and 
may  be  either  single  or  multiple  (Friedlander).  As  a  rule,  they 
do  not  exceed  3  oz.  in  weight,  but  in  the  case  related  by 
Tidemand  the  mass  weighed  1,500  grm. 

The  local  effects  of  a  concretion  consist  of  dilatation  of  the 
stomach  with  chronic  inflammation  and  atrophy  of  its  mucous 
membrane,  while  occasionally  the  organ  becomes  fixed  by 
adhesions  to  the  pancreas  or  abdominal  wall  (May).  When 
the  oesophagus  or  the  duodenum  is  involved  the  orifices  may  be 
greatly  dilated.  In  more  than  one-half  of  the  cases  death 
occurred  from  perforation  of  the  stomach  in  the  pyloric  region, 
or,  as  in  those  related  by  Gull  and  Yeo,  from  a  similar  lesion  of 
the  duodenum.     Haematemesis  was  responsible  for  the  fatal 


278  HAIR-BALLS  AND    OTHER   CONCRETIONS. 

termination  in  one  instance  (Russell),  and  intestinal  obstruction 
in  several  others  (Ritchie,  Friedlander).  Occasionally  the 
chronic  irritation  of  the  mass  gives  rise  to  superficial  erosions 
or  even  to  papillomata  (Best). 

Symptoms. — The  symptoms  of  a  dyspepsia  due  to  the 
continued  presence  of  a  foreign  body  in  the  stomach  will 
obviously  vary  with  the  nature  and  size  of  the  irritant  substance, 
but  in  all  cases  the  immediate  cause  of  the  gastric  disorder 
is  to  be  found  in  a  chronic  inflammation  of  the  mucous  mem- 
brane excited  by  direct  contact  with  the  foreign  body.  When 
the  latter  is  small  and  only  comparatively  injurious,  the  gastritis 
does  not  differ  materially  from  other  varieties  met  with  in 
practice,  and  no  secondary  disease  of  the  stomach  or  intestines 
ensues;  but,  if  the  substance  be  of  considerable  size  and  of 
solid  consistence,  the  initial  gastritis  is  almost  invariably 
followed  by  ulceration  of  the  stomach  or  bowel,  and  the  case 
often  terminates  fatally  by  haemorrhage  or  perforation.  In 
these  latter  conditions  it  is  therefore  necessary  to  distinguish 
an  initial  dyspepsia,  in  which  the  gastric  symptoms  depend 
upon  simple  inflammation  of  the  stomach  from  the  terminal 
stage  which  is  characterised  by  evidences  of  ulceration. 

Hair-balls. — Out  of  the  twenty-five  cases  of  this  variety 
no  fewer  than  twenty-four  were  females,  the  youngest  of 
whom  was  eight  and  the  oldest  thirty-four  at  the  time  of  death 
or  operation.  There  were  never  any  indications  of  mental 
disease,  and  in  several  instances  it  was  expressly  mentioned 
that  the  patient  was  neither  hysterical  nor  particularly 
emotional. 

The  habit  of  hair-swallowing  is  usually  acquired  in  early 
life,  when  the  hair  is  worn  loose  upon  the  shoulders.  In  the 
majority  of  cases  it  originates  in  the  trick  frequently  practised 
by  young  girls  of  holding  a  lock  of  hair  in  the  mouth  while 
reading  a  book  or  of  biting  the  ends  of  a  coil  when  angry  or 
excited.  In  other  instances  it  seems  to  arise  from  the  inclin- 
ation, which  is  so  strongly  marked  in  certain  people,  to  fill 


HAIR-BALLS.  279 

the  mouth  with  any  substance  with  which  they  happen  to  be 
working,  such  as  cotton  in  the  case  of  dressmakers,  wool  or 
thread  among  weavers,  and  tow,  flock,  or  cocoanut  fibre 
among  those  engaged  in  the  manufacture  of  mattresses  or 
mats.  Finally,  it  may  be  due  to  some  acquired  eccentricity 
of  which  the  patient  herself  is  often  quite  unconscious.  Thus, 
in  one  case  the  husband  stated  that  whenever  his  wife  was 
unusually  interested  in  a  subject  she  invariably  pulled  out  two 
or  three  hairs  from  the  back  of  her  head  and  put  them  into  her 
mouth,  while  in  another  it  was  observed  that  the  lady  would 
frequently  pluck  hairs  from  her  children's  heads  when  she 
caressed  them  or  played  with  them.  In  the  instance  recorded 
by  Inman  the  patient  was  accustomed  to  clean  her  comb 
with  her  fingers,  and  quite  unwittingly  to  put  the  little  bunch 
of  loose  hair  into  her  mouth  instead  of  into  a  toilet  tidy.  In 
each  of  these  conditions  it  is  probable  that  the  mouth  and 
throat  became  so  tolerant  of  the  presence  of  the  foreign  sub- 
stance that  the  hairs  were  constantly  swallowed  with  the  saliva 
without  creating  any  unpleasant  symptoms. 

Until  the  concretion  has  attained  a  considerable  size  and 
has  seriously  diminished  the  capacity  of  the  stomach,  it  seldom 
produces  any  special  symptoms,  and  even  when  the  organ  is 
completely  filled  with  hair  the  patient  may  be  quite  free  from 
pain  and  vomiting  (Russell,  Thornton).  As  a  rule,  however, 
after  a  prolonged  period  of  more  or  less  pronounced  dyspepsia 
she  begins  to  experience  severe  pain  after  meals  with  flatulence, 
distention,  and  nausea.  Gradually  the  pain  becomes  localised 
to  the  epigastrium  or  left  hypochondrium,  and  is  increased  by 
exercise  or  pressure  upon  the  part.  Vomiting  is  seldom  absent, 
and  sometimes  occurs  after  every  meal.  The  ejecta  are  small 
in  quantity,  acid  in  reaction,  and  may  contain  altered  bile  if 
the  concretion  involves  the  duodenum.  Occasionally  the 
vomit  is  stained  with  blood,  but  hair  has  never  been  observed 
in  it.  Anaemia  is  always  a  noticeable  feature  of  the  case, 
and    may    be    accompanied    by    palpitation,    dyspnoea,    and 


28o 


HAIR-BALLS  AND    OTHER   CONCRETIONS. 


oedema  of  the  feet.  The  appetite  is  variable,  but  sometimes 
continues  good;  the  tongue  is  foul,  the  breath  offensive,  and 
attacks  of  diarrhoea  are  apt  to  alternate  with  periods  of  trouble- 
some constipation.  Progressive  loss  of  flesh  is  seldom  observed 
except  when  vomiting  is  excessive. 

Physical  Signs.— In  every  case  there  is  a  well-marked 
abdominal  tumour,  which  is  often  large  enough  to  be  visible 
through  the  parietes.     AVhen  the  concretion  is  comparatively 


Fig.   5. — Tumour  formed  by  a 
hair-ball  in  the  stomach. 


Fig.  6. —  Tumour  formed  by  a 
large  hair-ball  which  had  produced 
dislocation  of  the  stomach. 


small  the  tumour  is  globular  in  form  and  occupies  the  epi- 
gastrium, but  in  advanced  cases  it  approximates  closely  to  the 
shape  of  the  stomach,  and  was  variously  described  in  the 
recorded  cases  as  "kidney-shaped,"  "crescentic,"  or  "like  a 
spleen."  As  a  rule,  it  is  situated  in  the  epigastrium  and  left 
hypochondrium,  but  it  may  involve  the  umbilical  and  the  left 
lumbar  region.  In  Russell's  case  the  stomach  was  so  displaced 
that  the  pylorus  lay  in  the  pelvis  and  the  tumour  occupied  the 
whole  of  the  left  side  of  the  abdomen. 

On  palpation  the  mass  feels  hard,  smooth,  and  superficial, 


DURATION   AND    COMPLICATIONS.  28 1 

and  has  a  well-defined  lower  border.  It  is  dull  on  percussion 
and  seldom  tender,  except  after  prolonged  manipulation  or 
when  the  stomach  is  ulcerated.  One  of  the  principal  features 
of  the  tumour  is  its  extreme  mobility,  which  permits  it  to  be 
displaced  downward  and  to  the  left  or  to  be  pushed  upward 
beneath  the  costal  margin  in  the  direction  of  the  spleen.  At 
a  late  stage  of  the  complaint,  however,  adhesions  may  form 
which  fix  the  organ  to  the  pancreas  or  abdominal  wall  (May). 
Peristaltic  movements  of  the  stomach  are  rarely  visible,  but 
flatus  may  sometimes  be  seen  or  felt  in  the  tumour  (Best). 
Sometimes  other  hard,  globular,  and  movable  masses  may  be 
detected  to  the  right  of  the  navel  or  in  the  iliac  fossa  from  the 
presence  of  hair-balls  in  the  duodenum  or  ileum.  In  every 
case  the  tumour  enlarges  very  slowly,  and,  except  perhaps  for 
a  sensation  of  weight  or  dragging,  it  does  not  give  rise  to  any 
special  inconvenience. 

Duration  and  Complications. — The  duration  of  the  disease 
is  difficult  to  determine,  but  it  probably  averages  about  fifteen 
years.  In  May's  case  the  patient  was  known  to  have  practised 
hair-swallowing  for  twenty-two  years,  and  in  that  recorded  by 
Russell  the  tumour  had  been  detected  at  the  age  of  fourteen. 
From  its  slow  growth  during  adult  life  it  is  probable  that  the 
greater  part  of  the  concretion  is  formed  during  childhood. 
With  the  exception  of  two  instances  in  which  laparotomy  was 
performed,  all  the  cases  ended  fatally.  In  about  one-half 
death  was  due  to  ulceration  and  perforation  of  the  stomach; 
fatal  haematemesis  occurred  in  one  instance,  while  in  two 
others  intestinal  obstruction  was  responsible  for  the  lethal 
event.  In  all  the  rest  death  ensued  from  exhaustion  entailed 
by  vomiting  and  diarrhoea. 

Case  I. — A  girl,  eighteen  years  of  age,  had  suffered  for  some 
time  from  pain  and  vomiting  after  food,  a  capricious  appetite,  and 
looseness  of  the  bowels.  In  the  epigastrium  there  was  a  tumour 
about  the  size  of  an  orange,  globular  in  shape,  somewhat  movable, 
and  of  very  slow  growth.     The  patient  suddenly  became  collapsed, 


282  HAIR-BALLS  AND    OTHER   CONCRETIONS. 

and  died  of  peritonitis.  At  the  necropsy  the  stomach  was  found  to 
be  filled  by  a  mass  of  hair  and  string,  which  was  moulded  to  the 
shape  of  the  organ  and  measured  6  inches  long,  3!  inches  in 
width,  and  2^  inches  in  thickness.  A  second  cylindrical  mass 
measuring  14  inches  in  length  filled  the  duodenum  and  extended 
into  the  jejunum.  A  chronic  ulcer  of  the  stomach  had  perforated 
into  the  peritoneal  cavity. — Pollock. 

Case  II. — A  lady,  thirty-one  years  of  age,  was  suddenly  seized 
with  severe  haematemesis.  She  had  not  suffered  from  any  gastric 
symptoms  previously,  but  was  known  to  have  had  an  abdominal 
tumour  since  the  age  of  fourteen.  The  tumour  now  occupied  the 
whole  of  the  left  side  of  the  abdomen  and  extended  from  beneath  the 
left  costal  margin  to  the  pelvis.  It  moved  with  respiration,  was  dull 
on  percussion,  and  had  a  hard,  smooth  surface.  The  inner  border 
was  slightly  concave,  well  defined,  and  apparently  presented  a  notch 
about  its  centre.  It  resembled  a  spleen  in  every  particular,  with  the 
possible  exception  that  its  length  was  somewhat  out  of  proportion  to 
its  width.  The  haemorrhage  proved  fatal.  A  necropsy  showed  that 
the  tumour  was  composed  of  the  stomach,  which  was  almost  vertical 
in  position,  with  the  pylorus  in  the  cavity  of  the  pelvis.  Its  contents 
consisted  of  a  firm  mass  of  hair  measuring  12  inches  in  length,  5  in 
width,  and  4  in  thickness,  and  weighing  4  lb.  7  oz.  The  individual 
hairs  were  of  all  lengths  up  to  20  inches.  The  mucous  membrane 
near  the  great  curvature  was  ulcerated,  and  the  pylorus  was  dilated 
to  about  four  times  its  normal  size.  The  lady's  husband  stated  that 
whenever  his  wife  became  excited  she  was  in  the  habit  of  puUing 
two  or  three  hairs  from  her  head  and  putting  them  into  her  mouth. 
— Russell. 

Case  III. — A  factory  girl,  aged  twenty- one  years,  was  admitted 
into  hospital  with  the  symptoms  of  acute  intestinal  obstruction.  A 
large  movable  tumour  could  be  felt  in  the  epigastrum.  After  death 
the  stomach  was  found  to  contain  a  mass  of  hair  weighing  21 
oz.,  which  had  produced  extensive  ulceration  of  the  viscus.  The 
ileum  was  ruptured  just  above  the  caecum,  and  on  either  side  of  the 
lesion  there  was  a  ball  of  hair,  the  larger  of  which  weighed  i^ 
oz.  and  had  obstructed  the  intestine  at  the  ileo-csecal  valve. — 
Ritchie. 

Case  IV. — A  girl,  fifteen  years  of  age,  came  under  treatment  for 


VEGETABLE    TUMOURS.  283 

an  abdominal  tumour.  For  three  years  she  had  suffered  from  severe 
pain  and  vomiting  after  food.  The  tumour,  which  occupied  the 
epigastrium  and  left  hypochondrium,  felt  like  a  large  kidney  with  the 
hilus  upward  and  to  the  right.  It  was  hard,  freely  movable,  dull 
on  percussion,  and  somewhat  tender.  An  exploratory  operation 
proved  that  it  was  contained  in  the  stomach,  and  when  the  organ 
was  incised  a  large  mass  of  hair  was  found  and  removed.  After  the 
patient  had  recovered  it  was  ascertained  that  for  at  least  four  years 
she  had  been  accustomed  to  swallow  hair  in  order  to  improve  her 
voice. — Schonhorn. 

Vegetable  Tumours. — These  are  even  rarer  than  the 
preceding,  and  consist  of  undigested  vegetable  material,  fruit 
skins,  cherry  stalks,  or  the  fibrous  roots  of  certain  plants 
which  have  been  swallowed  on  account  of  their  reputed  medici- 
nal virtues. 

Except  that  they  occur  at  a  somewhat  later  period  of  life, 
the  symptoms  are  similar  to  those  already  noted.  For  several 
years  there  is  complaint  of  pain  and  vomiting  after  food,  with 
loss  of  appetite,  emaciation,  and  an  irregular  action  of  the 
bowels.  Occasionally  hsematemesis  and  cachexia  are  also 
observed.  The  tumour  is  seldom  as  large  as  a  hair-ball,  and 
is  usually  globular  in  shape  and  situated  in  the  epigastrium. 
As  a  rule,  death  ensues  from  perforation  of  the  stomach, 
haemorrhage,  or  exhaustion,  but  occasionally  the  foreign  body 
undergoes  disintegration  and  is  either  vomited  or  evacuated 
by  the  bowel. 

Case  V. — An  individual,  fifty-two  years  of  age,  came  under 
medical  treatment  for  severe  pain  and  vomiting  after  food,  with 
progressive  loss  of  flesh.  Hsematemesis  had  occurred  at  intervals, 
and  there  was  marked  cachexia.  In  the  epigastrium  a  round  tumour 
the  size  of  a  small  apple  could  be  felt,  which  was  dull  on  per- 
cussion, movable,  and  slightly  tender.  The  diagnosis  was  obscure, 
and  opinions  varied  between  enlarged  spleen,  a  floating  kidney, 
and  malignant  disease  of  the  stomach  or  transverse  colon.  Death 
occurred  from  exhaustion  at  the  end  of  three  years.  At  the  necropsy 
the  tumour  was  found  to  be  within  the  stomach,  and  to  consist  of  a 


284  HAIR-BALLS  AND    OTHER   CONCRETIONS. 

kidney-shaped  mass  of  vegetable  matter  weighing  29  oz.,  with  two 
other  masses,  each  about  the  size  of  a  hen's  egg. — Kooyker. 

Case  VI. — A  woman,  aged  forty-three  years,  complained  of 
violent  pain  in  the  abdomen  after  meals,  vomiting,  and  constipation. 
Under  the  ensiform  cartilage  a  hard,  fixed,  and  tender  tumour  could 
be  felt.  After  these  symptoms  had  existed  for  a  considerable  time 
an  exceptionally  violent  fit  of  vomiting  caused  the  expulsion  of  a 
large  sodden  mass  of  vegetable  matter,  after  which  the  patient 
made  a  good  recovery. — Capelle. 

Case  VII. — A  woman,  forty-five  years  of  age,  was  admitted  into 
hospital  for  an  abdominal  tumour  accompanied  by  pain  and  vomit- 
ing. The  tumour  resembled  a  large  spleen,  but  as  it  was  ascertained 
that  the  patient  had  eaten  a  quantity  of  a  plant  which  supersitition 
endowed  with  marvellous  powers  of  healing,  a  diagnosis  of  phyto- 
bezoar was  made,  and  a  large  mass  of  fibrous  roots  was  successfully 
removed  from  the  stomach  by  operation. — Schreiber  and  Eiselsherg. 

Gastroliths. — The  subjects  of  this  curious  complaint  are 
usually  men  about  middle  age  who,  in  their  morbid  desire  for 
alcohol,  frequently  have  drunk  varnish,  polish,  or  similar 
liquids  containing  it.  As  a  rule,  the  stone  is  too  small  to  be 
detected  during  life,  but  in  the  case  recorded  by  Tidemand 
a  large,  hard  tumour  could  be  felt  in  the  epigastrium.  Symp- 
toms of  gastric  irritation  with  vomiting  are  almost  always 
present  and  haematemesis  is  sometimes  observed.  Death 
ensues  from  exhaustion,  perforation  of  the  stomach,  or  from 
intestinal  obstruction  (Friedlander,  Langenbuch). 

Case  VIII. — A  polisher,  forty-four  years  of  age,  was  admitted 
into  hospital  with  the  symptoms  of  chronic  gastritis.  He  was  ex- 
tremely intemperate  in  his  habits,  and  the  gastric  disorder  was  conse- 
quently attributed  to  alcoholism.  After  the  lapse  of  some  months  he 
succumbed  to  pulmonary  tuberculosis.  At  the  necropsy  a  chronic 
ulcer  was  found  in  the  stomach  near  the  pylorus,  and  close  to  it  an 
oblong  mass  of  stone  which  measured  10  cm.  in  length  and  5  cm. 
in  width,  and  weighed  75  grammes.  Chemical  examination  showed 
the  concretion  to  be  composed  of  shellac,  and  it  was  afterward 
ascertained  that  the  man  had  been  accustomed  to  drink  the  polish 


DIAGNOSIS.  285 

he   used   in   his    work,  which    consisted   of   shellac   dissolved   in 
alcohol. — Manasse. 

Diagnosis. — It  is  probable  that  small  concretions  not 
infrequently  occur  in  young  girls  who  bite  or  suck  their  hair; 
but  when  the  habit  is  discontinued,  as  it  usually  is  after  the 
hair  has  been  dressed  in  the  adult  style,  the  material  is  gradually 
evacuated  without  the  production  of  serious  consequences. 
In  one  very  obstinate  case  of  dyspepsia  which  came  under  my 
notice  the  sides  of  the  forehead  had  been  quite  denuded  of  hair 
by  this  pernicious  habit,  and  it  was  only  after  the  dangers 
attending  a  hair  tumour  had  been  explained  to  the  young 
lady  and  measures  adopted  to  prevent  a  repetition  of  the 
practice  that  the  gastric  complaint  gradually  disappeared.  It 
is  therefore  advisable  that  in  every  case  of  obstinate  dyspepsia 
in  a  ^irl  careful  enquiries  should  be  instituted  with  regard  to 
~heT  habits  and  occupations,  and  that,  whenever  an  abdominal 
Tumour  is  discovered  in  a  young  adult,  the  possibility  of  a  \ 
foreign  body  in  the  stomach  should  be  borne  in  mind. 

If  pain  and  vomiting  are  prominent  features  of  the  case,  the 
discovery  of  a  tumour  in  the  abdomen  is  usually  suggestive 
of  malignant  disease  of  the  stomach  or  intestine.  In  such 
cases  three  points  deserve  special  attention,  namely,  the  age 
and  sex  of  the  patient,  the  duration  of  the  complaint,  and  the 
character  of  the  tumour.  Cancer  of  the  stomach  is  very  rare 
before  the  age  of  thirty,  and  its  precocious  development  is 
chiefly  met  with  in  men,  while  hair  tumours  commence  at  or 
before  puberty  and  are  practically  confined  to  women.  The 
mahgnant  disease  is  seldom  preceded  by  symptoms  of  indiges- 
tion, and  usually  runs  such  a  rapid  course  in  young  persons 
that  life  is  destroyed  withm  seven  months;  gastric  concretions, 
on  the  other  hand7are  attended  for  a  long  time  by  pain  and 
sickness  after  meals,  and  seldom  prove  fatal  in  less  than  ten 
years.  Lastly,  a  cancerous  tumour  is  irregular,  nodular,  tender, 
more  or  less  fixed  in  position,  and  of  rapid  growth,  while  in 
most  instances  the  stomach  is  dilated,  marked  cachexia  is  pres- 


286  HAIR-BALLS  AND    OTHER   CONCRETIONS. 

ent,  and  the  gastric  contents  are  devoid  of  free  hydrochloric 
acid.  A  hair  tumour,  on  the  other  hand,  is  globular  or  cres- 
centic  in  shape,  situated  principally  in  the  left  side  of  the  abdo- 
men, is  smooth,  hard,  and  painless  on  palpation,  and  so  freely 
movable  that  it  may  be  pushed  under  the  left  costal  margin. 
There  is  no.  ascites  or  jaundice,  the  outlines  of  the  stomach 
are  indistinguishable  from  those  of  the  tumour,  and  a  tube 
cannot  be  inserted  more  than  2  inches  into  the  viscus. 

A  painless  tumour  in  the  upper  part  of  the  abdomen, 
which  is  not  attended  by  special  symptoms  and  has  been  dis- 
covered in  an  accidental  manner,  is  most  likely  to  be  confused 
with  an  enlarged  spleen,  a  floating  kidney,  or  a  faecal  accumula- 
tion in  the  colon. 

If  the  stomach  happens  to  be  dislocated,  as  in  Russell's 
case,  the  diagnosis  from  an  enlarged  spleen  is  extremely  diffi- 
cult. It  may  usually  be  observed,  however,  that  the  tumour 
is  exceptionally  movable,  and  that  its  length  is  out  of  propor- 
tion to  its  breadth.  The  inner  margin  is  less  distinct  than  in 
the  case  of  a  spleen,  the  characteristic  notch  is  absent,  and 
the  passage  of  a  soft  tube  or  inflation  of  the  stomach  will  at 
once  show  that  the  tumour  is  gastric  in  origin.  A  loose  kidney 
on  the  left  side  can  usually  be  displaced  downward  as  well  as 
upward,  and  its  point  of  attachment  is  much  lower  than  that 
of  an  enlarged  stomach.  It  also  lies  behind  the  intestine,  so 
that  the  percussion  note  is  resonant  rather  than  dull,  and 
manipulation  is  often  attended  by  pain.  In  case  of  doubt, 
inflation  of  the  stomach  should  be  practised,  when  the  relation 
of  that  organ  to  the  tumour  can  easily  be  ascertained. 

A  faecal  mass  in  the  colon  is  more  irregular  in  shape  and 
less  definite  in  outline  Than  a  gastric  concretion.  It  is  less 
hard  to  the  touch,  and  may  even  be  soft  enough  to  indent  with 
the  finger,  while  other  tumours  of  a  similar  character  may  be 
found  in  the  caecum,  sigmoid  flexure,  or  rectum.  The  passage 
of  a  tube  shows  that  the  stomach  is  empty  and  situated  above 
the  tumour,   and   the   administration   of   several  large   ene- 


TREATMENT.  287 

mata  will  either  diminish  the  size  of  the  mass  or  remove  it 
altogether. 

Treatment. — If  the  tumour  is  small  in  size,  it  may  be 
possible  to  secure  its  evacuation  by  an  emetic;  but  this  method 
is  always  fraught  with  a  certain  amount  of  danger,  on  account 
of  the  ulceration  of  the  stomach  which  is  often  present.  In 
the  case  of  large  tumours  medicinal  remedies  are  valueless,  and 
recourse  must  be  had  to  an  operation.  In  the  cases  reported 
by  Knowsley  Thornton  and  Schonborn  the  mass  was  success- 
fully removed  after  the  nature  of  the  tumour  had  been  deter- 
mined by  an  exploratory  incision,  while  in  that  recorded  by 
Schreiber  a  correct  diagnosis  of  phytobezoar  was  made  by  the 
physician  and  the  concretion  extracted. 

(2)  LIVING  CREATURES. 

The  frequent  occurrence  of  entozoa  in  the  human  subject 
is  probably  responsible  for  the  superstitions  that  have  been 
current  for  many  centuries  regarding  the  harbourage  in  the 
stomach  of  various  strange  animals,  which,  subsisting  upon 
the  food  of  their  host  or  even  upon  the  structures  of  the 
viscera  give  rise  to  a  series  of  weird  symptoms  that  usually 
terminated  in  an  agonising  death.  Such  stories  not  only 
obtained  credence  among  all  classes  of  the  population  through- 
out the  entire  world,  but  have  frequently  been  recorded  and 
commented  upon  by  members  of  the  medical  profession,  many 
of  whom  appear  to  have  been  genuinely  convinced  that  the 
animals  shown  to  them  had  actually  escaped  from  the  body. 
So  many  of  these  fables  were  obviously  the  outcome  of  gross 
superstition,  hysteria,  or  of  a  deliberate  intention  to  defraud 
that  it  is,  perhaps,  hardly  surprising  that  modern  writers  on 
diseases  of  the  digestive  organs  either  ignore  the  subject 
altogether  or  merely  mention  the  occasional  occurrence  of 
accidental  parasitism.  Nevertheless,  instances  are  still  re- 
corded from  time  to  time  in  which  some  unusual  inhabitant  of 
the  human  body  has  been  observed  by  credible  witnesses,  and 


288  LIVING   CREATURES. 

with  very  little  trouble  more  than  one  hundred  and  eighty 
cases  may  be  collected  in  which  hzards,  frogs,  tritons,  slugs, 
caterpillars,  worms,  leeches,  beetles,  maggots,  larvse,  or  chrys- 
alides were  harboured  in  the  digestive  tract  for  a  considerable 
time  and  accompanied  by  an  intractable  form  of  dyspepsia. 
Some  of  these  are  so  well  authenticated  that  the  subject  cer- 
tainly seems  to  merit  more  attention  than  has  hitherto  been 
accorded  to  it. 

(i)  Insects. — A  large  number  of  different  insects  or  their 
larv£e  have  been  observed  as  accidental  inhabitants  of  the 
human  body  and  in  the  early  part  of  last  century,  Hope 
pubhshed  a  list  of  some  forty-three  varieties  that  had  been 
identified.  Since  that  time  numerous  other  cases  have  been 
recorded  and  there  is  now  little  difficulty  in  collecting  one 
hundred  and  thirty  examples  of  myiasis,  or  diseases  caused  by 
the  presence  of  insects.  In  the  vast  majority,  where  sufficient 
details  are  given  to  permit  of  their  identification,  the  insects 
belonged  to  three  of  the  fifteen  natural  orders,  namely,  the 
Diptera,  or  two-winged  flies,  the  Coleoptera,  or  beetles,  and  the 
Lepidoptera,  or  butterflies  and  moths,  and  it  is  with  the  various 
species  belonging  to  these  three  orders  that  the  following 
remarks  are  chiefly  concerned. 

Diptera. — Of  the  numerous  families  of  this  order,  the 
Muscidae,  which  include  the  house-flies,  blow-flies,  flesh-flies, 
and  flower-flies,  contribute  the  greatest  number  of  parasitic 
larvse.  The  eggs  of  these  insects  are  usually  deposited  in 
places  where  an  abundance  of  food  is  obtainable  without  the 
necessity  of  exertion,  and  consequently  the  resultant  larvae 
constitute  the  lowest  form  of  maggots  and  possess  no  legs. 
A  very  short  time  may  intervene  between  the  deposition  of  the 
egg  and  the  appearance  of  the  larva,  which  in  the  case  of  the 
blow-fly  does  not  exceed  twenty-four  hours.  As  a  rule,  the 
common  house-fly  (Musca  domestica)  lays  her  eggs  upon 
various  forms  of  cooked  meats,  sweets,  or  biscuits,  while  the 
blue-bottle,  or  blow-fly  (^lusca  vomitoria),  prefers  high  meat, 


INSECTS.  289 

game,  or  other  forms  of  animal  food  that  are  undergoing 
decomposition.  In  his  description  of  the  latter  species,  Wood 
remarks  that  the  oval  wire  covers  which  are  sold  for  the  purpose 
of  keeping  blow-flies  from  meat  are  often  useless,  since,  when 
the  insect  finds  that  she  cannot  gain  direct  access  to  the  meat, 
she  will  rest  upon  the  top  of  the  cover  and  allow  her  eggs  to 
drop  through  the  mesh  of  the  wire  gauze.  The  flesh-fly,  or 
baker  as  it  is  often  called  (Musca  carnaria),  proceeds  in  a 
different  and  more  expeditious  manner.  In  the  case  of  the 
blue-bottle  and  most  other  Muscidae  the  eggs  have  to  be 
hatched  after  their  deposition,  but  in  this  species  they  are 
hatched  within  the  body  of  the  parent  and  are  deposited  as 
maggots,  each  female  producing  about  twenty  thousand. 
It  was  to  such  insects  that  Linnaeus  referred  when  he  wrote 
the  apparent  paradox  that  three  flies  could  eat  an  ox  as  fast 
as  a  lion.  The  flesh-fly  does  not  even  wait  until  the  meat 
has  undergone  incipient  decomposition,  or,  perhaps,  is  able 
to  detect  signs  of  it  before  they  become  apparent  to  the  human 
senses,  since  hosts  of  these  minute  larvae  are  often  found  upon 
birds  and  animals  within  two  hours  of  their  death.  Of  the 
genus  Anthomyia  some  species,  such  as  the  meat-fly  (Musca 
anthomyia),  particularly  affect  meat,  while  others  feed  on 
radishes  or  onions  (A.  ceparum),  lettuces  (A.  lactucae),  or 
cabbage  (A.  brassicae).  Others,  again,  deposit  their  eggs  in 
certain  fruits,  especially  the  raspberry  and  blackberry,  each 
specimen  of  which  when  fully  ripe  may  be  found  to  contain  a 
maggot.  The  number  of  eggs  and  larvae  which  find  entrance 
to  the  stomachs  of  persons  who  devour  garden  and  hedge-row 
fruits  must  be  enormous.  In  two  apparently  authentic  cases 
(Lasalle,  Sentex)  larvae  belonging  to  the  family  of  the  Tipulidae, 
or  crane-flies,  were  detected  in  the  vomit  and  faeces.  The 
best  known  species  is  the  Tipula  longicornis,  or  daddy-long-legs, 
which  deposits  its  eggs  upon  the  ground  whence  they  may 
possibly  gain  access  to  the  human  stomach  through  the 
medium  of  unwashed  vegetables.  The  grubs,  which  are  tough- 
19 


290  LIVING   CREATURES. 

skinned  and  hard-headed,  are  only  too  well  known  to  gardeners 
by  the  name  of  leather- jackets.  The  larvae  of  other  species 
live  in  rain  water  in  which  they  appear  like  minute  pieces  of 
scarlet  thread  that  exhibit  constant  twisting  movements. 
Occasionally  the  larvse  of  the  drone-fly  (Eristalis  tenax)  find 
their  way  into  the  human  stomach  through  the  medium  of 
water,  although  the  muddy  fluid  usually  favoured  by  these 
rat-tailed  maggots  can  hardly  be  described  as  suitable  for 
drinking  purposes.  Drosophila  larvse  are  sometimes  ingested 
in  sour  milk  (Hutton)  and  the  well-known  cheese  mite  (Piophila 
casei) ,  which  is  probably  quite  harmless,  needs  no  description. 
Another  dipterous  insect  that  lays  her  eggs  upon  the  surface 
of  water  is  the  common  gnat  (Culex  pipiens)  and  Allonneau 
has  recorded  an  instance  in  which  immense  numbers  of  eggs 
and  larvae  of  this  insect  were  vomited  at  intervals.  The 
family  of  CEstridae  or  botflies  are  parasitic  in  certain  animals, 
the  larvae  of  the  common  botfly  (Gasterophilus  equi)  infesting 
the  stomach  of  the  horse.  Several  cases  have  been  recorded 
in  tropical  countries  in  which  persons  vomited  or  evacuated 
larvae  of  these  species,  while  the  one  related  by  Cattle  is  of 
especial  interest  since  it  occurred  in  an  inhabitant  of  this 
country  who  was  not  concerned  in  tending  domestic  animals. 
Coleoptera. — At  least  twenty-four  varieties  of  beetles  or 
their  larvae  have  been  identified  in  the  vomit  or  evacuations 
of  patients  suffering  from  symptoms  of  gastrointestinal  irri- 
tation, and  more  than  forty  instances  may  be  found  recorded 
in  the  literature.  In  the  great  majority  the  insects  apparently 
belonged  either  to  the  Staphylinidae,  or  rove  beetles,  the  Car- 
abidae,  or  ground  beetles,  or  to  the  Blaptidae,  among  the  latter 
of  which  the  Blaps  mortisaga,  or  churchyard  beetle,  is  the 
most  conspicuous  example,  its  existence  having  been  specific- 
ally mentioned  in  nine  instances.  In  some  cases  many  different 
species  were  found  in  the  same  individual  mixed  with  larvae 
of  dipterous  insects,  spiders,  millipedes,  and  entozoa.  The 
eggs  of  many  of  these  beetles  are  deposited  in  the  earth, 


INSECTS.  291 

although  those  of  Tenebrio  molitor  are  usually  found  in  corn 
mills  and  bakehouses  and  probably  find  their  way  into  the 
stomach  with  the  flour  or  bread.  All  the  larvae  are  of  con- 
siderable size,  those  of  the  Blaps  mortisaga  often  measuring 
an  inch  and  a  half  in  length,  and  as  they  are  provided  with 
very  formidable  feet  and  jaws,  their  existence  in  the  stomach 
and  intestines  of  their  human  host  is  usually  productive  of 
anything  but  comfort.  If  well  supphed  with  food  and  warmth 
the  Tenebrio  molitor  and  perhaps  other  species  breed  through- 
out the  entire  year,  a  fact  which  may  help  to  explain  the 
persistent  evacuation  of  the  insects  in  all  stages  of  their  develop- 
ment, which  was  noted  in  the  cases  of  Mary  Riordan  and 
others. 

Lepidoptera. — Members  of  this  order  are  less  frequently 
parasitic  in  the  human  subject  than  the  diptera  or  coleoptera. 
Caterpillars  of  the  Noctuae  have  been  evacuated  alive  in  six 
instances,  and  in  four  others  those  of  the  Mamestra  brassicae, 
or  cabbage  moth,  which  infest  the  summer  cabbage  have  been 
identified;  while  in  one  instance  (Herold)  the  caterpillar  of 
the  large  white  butterfly  (Pieris  brassicae)  has  been  found. 
In  all,  some  twenty-two  parasitic  caterpillars,  generally 
referred  to  as  "hairy"  or  "smooth"  have  been  observed,  while 
Cavenne  has  recorded  an  instance  in  which  chrysahdes  of 
butterflies  were  the  cause  of  a  severe  gastroenteritis.  Finally, 
it  may  be  mentioned  that  Bartels  has  observed  internal 
parasitism  by  a  member  of  the  family  of  the  Pulicidas,  or  fleas, 
and  Ranque  a  case  where  numerous  wood-hce  were  vomited. 

Gastrointestinal  infection  by  dipterous  insects  is  far  more 
common  in  tropical  countries  than  in  England,  owing  to  the 
greater  number  and  variety  of  flies  and  the  habit  of  eating 
meat  in  a  half-cooked  state.  Even  in  England,  however,  it  is 
probable  that  the  majority  of  people  who  enjoy  cold  game 
or  stale  cooked  meats  during  the  warm  months  of  the  year 
invariably  swallow  eggs  and  even  larvae  of  these  insects,  while 
those  who  indulge  in  garden  fruits,  raw  cabbages,  salads. 


292  LIVING   CREATURES. 

omons,  or  radishes  which  have  been  carelessly  cleaned  are  also 
extremely  prone  to  infection  by  the  various  Anthomyia  as 
well  as  by  other  insects  that  feed  upon  these  substances.  It  is 
stated  that  the  eggs  of  the  blow-fly  have  been  found  in  the 
evacuations  of  healthy  individuals,  and  it  is  probable  that  if  a 
systematic  investigation  were  undertaken  the  eggs  and  larvae 
of  other  genera  would  also  be  detected.  The  habit  of  drinking 
unboiled  water  or  water  that  has  been  exposed  to  the  air  for 
some  time  is  responsible  for  infection  by  those  species  that 
usually  lay  their  eggs  on  water,  while  persons  who  drink  the 
contents  of  pools,  lakes,  wells,  or  tanks  invite  infection  by  a 
vast  number  of  larvse. 

The  fact  that  the  rat-tailed  grub  of  the  drone-fly,  which 
selects  for  its  residence  only  the  foulest  water,  has  been  found 
in  the  human  stomach  is  sufficient  to  indicate  how  widely 
opinions  may  differ  concerning  the  exact  definition  of  "  drinking 
water. "  Cakes,  biscuits,  or  sweets  kept  in  cupboards  are  liable 
to  be  contaminated  by  many  insects,  and  in  the  case  related 
by  Albrecht  it  was  observed  that  the  larvae  in  the  boy's  stools 
were  identical  with  those  which  infested  a  cupboard  in  which 
his  favourite  cakes  were  stored.  A  depraved  appetite  resulting 
from  hysteria  or  mental  disease  seems  to  have  been  responsible 
for  many  examples  of  coleopterous  larvae  in  the  human  sub- 
ject, although  the  fact  that  children  are  by  no  means  exempt 
(Pickells)  proves  that  accidental  infection  may  sometimes 
occur,  possibly  through  the  medium  of  garden  mould. 

The  clinical  details  of  many  of  the  cases  of  internal  myiasis, 
while  deficient  in  several  important  particulars,  conclusively 
prove  that  under  certain  circumstances  the  eggs  of  insects  are 
hatched  in  the  human  stomach  and  the  resultant  larvae  grow 
to  their  full  size;  while  in  rarer  instances  all  the  various 
metamorphoses  which  precede  the  development  of  the  perfect 
insect  may  be  completed  in  the  organ.  Thus,  more  than 
forty-five  examples  have  been  recorded  where  a  vast  number 
of  maggots  were  evacuated  as  the  result  of  the  ingestion  of 


INSECTS.  293 

insects'  eggs  and  in  many  of  these  the  length  of  time  which 
elapsed  between  the  probable  date  of  infection  and  the  first 
discharge  of  living  larvae  corresponded  with  that  required 
for  the  hatching  of  the  eggs  and  the  development  of  the  mag- 
gots. In  other  instances,  again,  as  in  that  related  by  Cavenne, 
the  appearance  in  the  stools  of  chrysahdes  suggests  that  the  pu- 
pal as  well  as  the  larval  stage  was  completed  in  the  ahmentary 
tract,  while  the  case  of  Mary  Riordan  and  others  in  which 
larvae,  pupae,  and  perfect  insects  were  discharged  at  intervals 
for  years  can  only  be  explained  by  the  assumption  that  the 
insects  actually  multipHed  in  the  digestive  canal  of  their 
host.  These  clinical  observations  are  to  some  extent  con- 
firmed by  the  results  of  experiment.  Thus,  the  larvae  of  flies 
introduced  into  the  stomachs  of  guinea-pigs  and  frogs  have 
been  found  ahve  at  the  expiration  of  three  days,  and  those 
of  the  blow-fly  not  only  withstand  prolonged  immersion  in 
water,  but  resist  artificial  peptic  and  pancreatic  digestion  for 
six  or  seven  hours.  The  extraordinary  vitality  of  many 
species  of  beetles,  especially  the  Blaptidse,  has  frequently 
excited  comment  (Pickells)  and  even  immersion  in  spirits  of 
wine  for  several  hours  does  not  seem  to  affect  the  Blaps 
mortisaga  (Wood). 

It  is  quite  certain,  therefore,  that  not  only  do  the  eggs  of 
dipterous  and  coleopterous  insects  frequently  hatch  in  the 
human  stomach,  but  that  the  larvae  may  remain  alive  in  the 
organ  sufficiently  long  to  permit  their  escape  into  the  more 
hospitable  regions  of  the  intestine.  If  these  statements 
apply  to  the  normal  stomach  they  become  infinitely  more 
forcible  when  the  frequent  occurrence  of  gastric  subacidity 
is  considered.  It  is  well  known  that  certain  functional 
disorders  of  the  nervous  system,  including  neurasthenia, 
hysteria,  and  some  forms  of  insanity,  are  not  infrequently 
accompanied  by  a  marked  deficiency  of  hydrochoric  acid  in 
the  gastric  secretion,  and  since  all  varieties  of  primary  in- 
flammation of  the  stomach  induce  a  similar  diminution  of 


294  LIVING   CREATURES. 

digestive  activity,  it  is  obvious  that  the  gastritis  which  ensues 
from  the  presence  of  hving  animals  must  indirectly  favour 
their  longevity,  It  is  also  highly  probable  that  the  condition 
known  as  achylia  gastrica,  in  which  the  stomach  never  secretes 
any  acid,  is  far  more  common  than  is  usually  supposed,  and 
consequently  in  many  apparently  healthy  individuals  the 
stomach  will  act  merely  as  an  incubator  which  presents 
every  convenience  for  the  development  of  any  eggs  that  may 
happen  to  gain  entrance  to  it. 

Symptoms. — The  symptoms  that  ensue  from  the  presence 
of  larvse  in  the  alimentary  tract  vary  according  to  the 
numbers  and  nature  of  the  parasite.  In  the  case  of  the 
Muscidae  the  passage  of  maggots  by  the  rectum  is  often  the 
first  indication  of  the  disease;  but  when  larvae  of  the  CEstridse, 
Tipulidae,  or  Coleoptera  are  present,  their  large  size  and  sharp 
appendages  always  give  rise  to  considerable  irritation.  An 
interval  of  four  to  twelve  days  usually  intervenes  between  the 
ingestion  of  the  insect's  eggs  and  the  appearance  of  the  first 
symptoms,  during  which  time  the  patient  either  feels  perfectly 
well  or  complains  of  vague  abdominal  discomfort,  restlessness, 
and  want  of  appetite.  At  the  end  of  this  incubation  period, 
general  malaise  is  usually  experienced  accompanied  by  head- 
ache, thirst,  anorexia,  and  faintness,  while  in  children  rigors, 
convulsions,  and  delirium  are  not  infrequent.  Extreme 
vertigo  has  been  mentioned  in  so  many  cases  that  its  occurrence 
cannot  be  regarded  as  purely  accidental.  Fever  occurs  in 
more  than  half  the  cases  and  may  persist  for  ten  days  or 
longer,  although,  as  a  rule,  it  tends  to  subside  within  forty- 
eight  hours;  in  several  instances  continued  pyrexia  for  three 
weeks  accompanied  by  looseness  of  the  bowels  caused  the 
case  to  be  diagnosed  as  one  of  enteric  fever  (May).  When 
dipterous  larvae  inhabit  the  intestine  the  abdominal  symptoms 
are  usually  slight  and  consist  chiefly  of  distention,  uneasiness, 
or  of  pinching  and  pricking  sensations  in  the  region  of  the 
navel;  but  if  those  of  beetles,  botflies,  or  crane-flies  are  pres- 


SYMPTOMS.  295 

ent,  severe  tearing  or  gnawing  pains  are  often  complained  of, 
or  genuine  colic  is  experienced.  Retching  and  vomiting  occur 
in  the  majority  of  cases  where  these  latter  larvae  exist,  and  in 
more  than  one  instance  haematemesis  has  been  observed.  The 
crisis  of  the  complaint  which  seems  to  coincide  with  maturity 
of  the  larvae  is  heralded  by  the  sudden  evacuation  of  the 
parasites,  dipterous  maggots  being  usually  discharged  by  the 
bowel  as  well  as  from  the  stomach,  while  beetle-larvae  are 
more  often  vomited.  Occasionally  only  a  few  are  eliminated 
at  a  time,  but,  as  a  rule,  their  numbers  have  been  reckoned 
by  the  pint,  quart,  or  litre,  or  were  described  as  innumer- 
able. It  is  interesting  to  notice  that  young  children  often 
suffer  from  general  urticaria,  especially  when  the  caterpillars 
of  certain  moths  have  been  swallowed.  The  evacuation  of 
the  maggots  is  almost  invariably  accompanied  by  a  rapid 
subsidence  of  all  the  former  symptoms,  with  the  exception 
of  a  mild  form  of  diarrhoea  which  may  persist  for  several 
days.  In  nearly  two-thirds  of  the  recorded  cases  the  symptoms 
recurred  within  fourteen  days,  and  in  about  40  per  cent,  of 
the  entire  number  the  patients  continued  to  discharge  larvae 
either  from  the  stomach  or  the  bowel  for  many  months.  In 
only  two  instances  was  any  mention  made  of  the  appearance 
of  the  fly  in  the  stools  or  vomit,  so  it  is  probable  that  the 
apparent  chronicity  of  the  disease  depended  upon  a  succession 
of  distinct  infections;  but  in  the  cases  of  coleopterous  parasitism, 
such  as  those  recorded  by  Pickells,  Ariel,  Patterson,  Bateman, 
and  others,  the  long  continuance  of  the  disease,  which  in 
Pickells'  patient  was  still  increasing  in  severity  after  three 
years,  indicates  that  the  insects  must  have  multiplied  within 
the  body  of  their  host.  Senator's  case  is  of  interest  from  the 
fact  that  while  no  maggots  could  be  obtained  by  washing  out 
the  stomach,  the  patient  vomited  twelve  more  about  a  month 
later.  In  only  one  instance  was  external  myiasis  associated 
with  discharge  of  larvae  from  the  bowel.  This  was  observed 
by  Pout  in  1787  and  concerned  a  girl  eleven  years  of  age 


296  LIVING   CREATURES. 

who  was  suffering  from  smallpox.  On  the  ninth  day  of 
the  disease  she  suddenly  passed  about  half  a  pint  of  live 
maggots,  and  in  all  about  three  quarts  were  discharged  from 
the  bowel.  As  the  pustules  burst  each  one  was  found  to 
contain  a  similar  maggot.  Death  occurred  from  exhaustion. 
The  medical  attendant  appears  to  have  been  so  surprised 
and  perplexed  by  these  curious  features  of  smallpox  that  it 
is  hardly  possible  to  regard  the  case  as  anything  but  genuine. 
Emaciation,  anaemia,  and  general  debility  are  usually  observed 
in  chronic  cases,  and  occasionally  mention  has  been  made 
of  a  depraved  appetite,  difficulty  of  micturition,  dyspnoea, 
and  dropsical  effusions.  The  general  features  presented  by 
beetle  parasitism  are  well  exemplified  by  the  case  of  Mary 
Riordan  which  excited  much  interest  during  the  third  decade 
of  last  century  and  was  so  carefully  watched  by  many  inde- 
pendent observers  for  the  space  of  three  years  that  even 
Cobbold  admitted  its  genuineness.  This  young  woman,  who 
was  highly  neurotic  and  steeped  in  superstition,  made  it  a 
practice  for  two  years  to  remove  clay  from  the  graves  of  some 
priests  of  extreme  sanctity  and  to  mix  it  with  her  daily  food. 
When  first  seen  by  Pickells  she  complained  of  severe  gnawing 
and  cramping  pains  in  the  abdomen,  nausea,  giddiness,  and 
retching  and  was  subject  to  attacks  of  catalepsy.  At  in- 
tervals violent  vomiting  would  occur  attended  by  the  ejection 
of  various  larvse  mixed  with  blood  and  mucus.  In  these 
attacks  the  patient  would  scream  with  pain  and  describe 
herself  as  suffering  the  tortures  of  hell,  or  even  exhibit  epileptic 
convulsions.  During  the  first  year  of  her  illness  seven  hundred 
larvae,  most  of  them  alive,  were  vomited  and  about  one 
hundred  passed  per  rectum;  while  in  the  course  of  the  next 
eighteen  months  nearly  thirteen  hundred  were  counted.  Most 
of  the  larvae  were  identified  as  those  of  the  Blaps  mortisaga,  or 
churchyard  beetle,  but  in  addition  to  these  the  meal-worm, 
or  larva  of  the  Tenebrio  molitor,  various  dipterous  maggots, 
and  intestinal  parasites  were  observed.     The  majority  of  the 


SYMPTOMS.  297 

larvae  were  full-grown,  those  of  the  Blaps  mortisaga  measur 
ing  i^  inches  in  length  and  being  apparently  omnivorous, 
they  frequently  devoured  each  other  when  kept  in  boxes  for 
observation.  Pupge,  as  well  as  perfect  insects  were  often 
seen,  and  on  one  occasion  when  two  beetles  were  vomited 
the  insects  flew  away.  For  three  and  a  quarter  years  these 
parasites  continued  to  increase  in  numbers,  and  the  patient 
remained  extremely  ill  and  suffered  from  dropsy,  retention  of 
urine,  and  other  notable  symptoms.  After  numerous  remedies 
had  been  tried,  the  administration  of  6  oz.  of  turpentine 
each  day  procured  the  evacuation  of  immense  numbers  of 
larvae,  pupse,  insects,  and  worms,  after  which  the  pain  and 
vomiting  subsided  and  the  girl  was  restored  to  health.  In 
Ariel's  case  the  patient  vomited  immense  numbers  of  beetles 
during  the  course  of  two  years,  including  two  hundred  and 
sixty-three  belonging  to  various  species  of  Staphlylinidae,  among 
which  were  identified  the  Ocypus  olens,  or  devil's  coach — 
horse,  as  well  as  numberless  larvae  of  the  Tenebrio  molitor 
and  of  different  species  of  Carabidae.  This  patient  was  cured 
by  a  mixture  of  turpentine  and  linseed  oil.  Osiander's  case, 
to  which  reference  has  already  been  made,  vomited  and 
passed  by  the  bowel  numerous  millipedes,  flies,  larvae,  beetles, 
spiders,  and  worms.  Colter  mentions  a  kaffir  girl,  eighteen 
years  of  age,  who,  after  suffering  for  a  long  time  from  abdominal 
pains,  vertigo,  and  loss  of  flesh,  vomited  every  few  days  a 
specimen  of  the  "dunghill-beetle";  while  in  the  cases  recorded 
by  Jessop,  Rosenstein,  and  others  living  larvae  of  various 
beetles  were  either  vomited  or  evacuated.  Very  little  is  known 
concerning  the  symptoms  produced  by  the  Lepidoptera,  most 
writers  being  content  to  refer  those  exhibited  by  their  respective 
cases  to  gastritis  or  enteritis.  In  one  described  by  Waters  a 
child  was  seized  with  high  fever,  delirium,  general  urticaria, 
and  indications  of  acute  gastritis,  all  of  which  subsided  after 
a  hairy  caterpillar  i^  inches  in  length  had  been  expelled 
from  the  bowel. 


298  LIVING   CREATURES. 

Treatment. — Accidental  parasitism  would  probably  be 
prevented  if  sufficient  care  were  taken  to  prevent  the  access 
of  flies  to  meat  and  other  articles  of  food  during  the  summer 
and  to  avoid  uncooked  vegetables,  musty  cakes  and  biscuits, 
and  unboiled  water.  Muslin  safes  are  alone  of  any  value  in 
protecting  meat  from  blow-flies.  In  mild  cases  of  internal 
myiasis  a  sharp  purge  is  sufficient  to  rid  the  intestines  of  the 
larvae  and  eggs,  while  in  the  more  troublesome  forms  the 
adminstration  of  thymol,  santonine,  or  other  anthelmintic 
often  appears  to  be  successful.  Beetles  are,  however,  notori- 
ously difficult  to  kill,  and  it  was  only  by  enormous  doses  of  tur- 
pentine that  Pickells  and  Ariel  were  able  to  rid  their  patients 
of  these  pests. 

■Slugs. — The  garden  slug  has  long  been  credited  with  the 
power  of  living  in  the  human  stomach  for  a  considerable  time 
(Triimpy).  Most  of  the  cases,  however,  which  are  supposed 
to  support  this  contention  are  extremely  doubtful,  although 
the  following  instance  reported  hy  Dickman  in  1859  presents 
certain  features  of  interest.  The  patient  was  a  girl  twelve 
years  old  who  was  in  the  habit  of  devouring  raw  vegetables 
in  the  garden.  For  two  months  she  had  complained  of  nausea 
and  discomfort  after  meals,  and  on  August  5th  vomited  a 
large,  active  garden  slug.  The  following  day  two  more  were 
vomited,  and  on  the  seventh  no  fewer  than  five  of  various  sizes. 
On  the  ninth  she  suddenly  exclaimed  that  something  was  crawl- 
ing up  her  throat  and  was  seized  with  violent  retching  and  chok- 
ing, at  the  same  time  making  desperate  efforts  to  extract  the 
animal  with  her  fingers.  A  mixture  of  ammonia  and  camphor 
gave  immediate  relief,  and  after  free  purgation  the  symptoms 
disappeared.  Three  of  the  slugs  were  preserved  and  it  was 
noted  that  for  a  time  they  ate  cooked  vegetables.  Dickman 
considered  that  the  girl  had  probably  swallowed  the  slugs 
when  they  were  extremely  small.  In  1865  Dalton  discussed 
the  question  whether  slugs  could  live  in  the  stomach  in  the 
light   of   certain   experiments.     He   stated   that   when   small 


LIZARDS.  299 

slugs  were  carefully  introduced  into  the  stomachs  of  dogs 
they  were  always  found  to  be  dead  when  the  animal  was  killed 
after  a  short  interval,  and  that  if  kept  in  water  at  a  temperature 
of  70°  F.  they  invariably  succumbed  within  twenty-four  hours. 
My  own  observations  indicate  that  garden  slugs  rapidly  die  in 
water  at  the  temperature  of  the  human  body,  although  they  are 
capable  of  living  in  a  moist  atmosphere  at  100°  F.  for  several 
hours.  On  the  other  hand,  immersion  in  the  filtered  contents 
of  a  healthy  human  stomach  which  possesses  the  normal 
degree  of  acidity  is  attended  by  an  immediate  coagulation  of 
their  mucilaginous  covering  and  death  within  a  few  minutes. 
It  can  only  be  assumed,  therefore,  that  if  Dickman's  observa- 
tions were  correct  his  patient  either  possessed  a  stomach  which 
secreted  no  acid  or  that  the  slugs  had  never  penetrated  lower 
than  the  cesphagus.  Rhind's  case,  in  which  a  common  grey 
slug,  4  inches  in  length,  is  stated  to  have  lived  in  the  stomach 
for  eighteen  months  and  to  have  survived  five  days  after  it  was 
vomited,  appears  to  have  been  similar  to  many  others  where 
hysterical  women  added  slugs  to  vomit  with  the  intention  of 
exciting  interest  or  compassion. 

Lizards. — In  1834  Luroth  published  the  case  of  a  woman 
twenty-eight  years  of  age,  who,  after  suffering  for  a  long  time 
from  gastralgia  and  other  symptoms  of  indigestion,  was  at- 
tacked with  severe  colic  and  voided  a  hzard  3  inches  in  length, 
after  which  all  her  former  symptoms  disappeared.  In  David's 
case  the  patient,  who  was  sixty  years  of  age,  was  cured  of 
severe  gastritis  after  vomiting  a  lizard,  while  in  that  related 
by  Spence  the  reptile  voided  by  the  bowel  was  sufficiently  agile 
to  escape  capture.  In  these  as  well  as  in  other  instances 
(Bernstein,  Pingualt,  Hirzl)  the  sole  evidence  appears  to 
have  rested  upon  the  statements  of  the  patient,  and  the 
evacuation  of  the  animal  does  not  seem  to  have  been  ob- 
served by  any  independent  witness.  There  is  consequently 
no  reason  to  suppose  that  the  lizards  ever  inhabited  the 
alimentary  canal. 


300  LIVING   CREATURES. 

Worms. — Garden  worms  are  frequently  brought  to  medical 
men  with  the  story  that  they  had  been  vomited  or  evacuated 
by  the  bowel.  Several  instances  have  been  recorded  (Eyting, 
Fermaud,  Sutton)  in  which  the  ingestion  of  such  worms  was 
followed  by  severe  inflammation  of  the  stomach  and  intes- 
tines, but  there  is  no  evidence  that  they  remained  ahve  in  the 
digestive  tract  for  any  length  of  time. 

Leeches. — In  former  years  when  leeches  were  constantly 
employed  in  medical  practice,  many  instances  were  recorded 
in  which  they  were  accidentally  swallowed  with  serious  results, 
and  in  a  medical  treatise  pubhshed  in  1835  it  is  stated  that 
when  leeches  gain  access  to  the  human  stomach  they  grow 
to  an  immense  size  and  occasion  severe  losses  of  blood. 
Spence  claimed  to  have  removed  from  the  throat  of  a  patient  a 
leech  which  had  caused  spitting  of  blood  for  two  months; 
Dumas  relates  an  example  of  acute  gastritis  due  to  a  leech  in 
the  stomach;  Marques,  one  in  which  repeated  haematemesis 
occurred  during  the  course  of  twenty-two  days  from  the  same 
cause,  and  Wanderbach  a  somewhat  similar  instance.  There 
does  not  appear  to  be  any  reason  why  a  leech  should  not  enjoy 
a  comfortable  existence  in  the  human  stomach,  but  whether 
it  would  be  capable  of  sucking  blood  from  its  host  for  an  indefi- 
nite period  is  open  to  question.  It  is  comforting,  however,  to 
know  that  the  administration  of  a  strong  solution  of  common 
salt  is  a  certain  method  of  destroying  such  an  unwelcome 
parasite. 

Amphibious  Animals. — The  popular  belief  that  the 
stomach  always  contains  fluid  may  possibly  account  for  the 
superstition  that  certain  amphibia,  such  as  frogs  and  salaman- 
ders, are  able  to  pass  a  prolonged  existence  in  the  human 
body.  At  least  four  cases  have  been  recorded  in  which  the 
presence  of  Hving  frogs  appears  to  have  been  honestly  regarded 
by  doctors  as  the  cause  of  the  gastric  symptoms  presented  by 
their  patients  (Ille,  Sander,  v.  Wiebers,  Weis) .  In  two  instances 
only  one  frog  seems  to  have  existed,  while  Sander's  case  was 


AMPHIBIOUS    ANIMALS.  30I 

remarkable  from  the  fact  that  no  fewer  than  nine  frogs  were 
vomited.  In  every  instance  the  patient  was  a  woman  who 
had  experienced  colicky  pains,  flatulence,  nausea,  and  loss 
of  flesh  for  some  time  previous  to  the  appearance  of  the  animal 
in  the  vomit.  Aquatic  salamanders,  as  occasional  inhabitants 
of  the  human  body,  have  been  recorded  by  Linckius  and  others, 
but  in  every  case  it  would  seem  that  the  reptile  had  been 
intentionally  swallowed.  Berthold  has  specially  investigated 
the  question  of  living  amphibia  in  the  human  stomach,  and  in 
two  instances  he  was  able  to  demonstrate  the  existence  of  flies 
and  other  insects  in  the  stomachs  of  reptiles  which  were  stated 
to  have  been  vomited  after  a  long  residence  in  the  patient's 
body;  while  a  salamander,  supposed  to  have  been  vomited  by 
a  girl,  died  when  placed  in  water  at  a  temperature  of  65°  F. 
This  observer  also  noted  that  frog-spawn,  tadpoles,  edible  frogs, 
and  salamanders  rapidly  die  when  the  temperature  of  the  water 
in  which  they  lived  was  raised  above  65°  F.  On  the  other 
hand,  at  least  two  cases  have  been  recorded  which  go  to  prove 
that  amphibia  are  able  to  resist  a  much  higher  temperature 
than  Berthold  was  inchned  to  admit.  Thus,  an  insane 
woman  under  the  care  of  Bresmer,  believing  that  the  reptile's 
bite  was  fatal,  attempted  to  commit  suicide  by  swallowing  a 
small  toad  which  she  had  carefully  wrapped  up  in  a  piece  of 
peritoneum  obtained  from  a  butcher's  shop.  No  symptoms 
of  interest  developed  for  several  hours,  but  in  the  course  of 
the  evening  she  complained  of  much  nausea  and  oppression 
at  the  chest  and  finally  vomited  the  toad,  alive  but  with  both 
hind  legs  broken.  Colin's  patient,  who  swallowed  a  live 
aquatic  salamander,  vomited  the  animal  alive  after  the  lapse 
of  sixty  hours.  With  regard  to  the  question  of  food  it  is  prob- 
able that  the  smaller  amphibia  and  reptilia  are  able  to  accom- 
modate themselves  to  existing  circumstances  to  a  much  greater 
degree  than  is  usually  believed.  Thus,  I  remember  some 
lizards  that  were  starving  to  death  during  an  exceptionally 
hard  winter  were  at  length  offered  warm  milk  which  they 


302  LIVING   CREATURES. 

licked  up  with  great  relish  and  soon  became  fat  upon  this 
novel  diet.  Although  there  is  no  reason  to  believe  that 
amphibia  ever  enjoy  a  prolonged  existence  in  the  human 
stomach  or  that  spawn  accidentally  swallowed  can  develop  into 
tadpoles,  it  does  not  seem  improbable  that  a  small  frog  if  un- 
injured in  transit  might  live  in  the  stomach  for  several  hours. 

With  regard  to  the  cases  in  which  live  fresh-water  shrimps 
are  stated  to  have  been  discovered  in  the  evacuations  (Banon, 
Troschel,  Wright),  I  have  never  known  these  Crustacea  live 
more  than  fifteen  seconds  in  water  at  the  temperature  of  the 
human  body. 

Snakes. — The  only  carefully  attested  instance  of  a  snake 
living  for  more  than  a  few  hours  after  being  swallowed  is  that 
recorded  by  Mandt.  The  subject  of  this  incident  was  a  Rus- 
sian peasant,  thirty-six  years  of  age,  who,  when  sleeping  in  a 
forest,  was  awakened  by  a  sensation  of  something  passing 
down  his  throat.  On  examination  a  rounded  body  endowed 
with  spontaneous  movement  could  be  felt  which  also  produced 
a  loud  bruit  that  was  audible  through  a  stethescope.  Various 
emetics  and  aperients  were  given,  but  the  movements  did  not 
cease  until  the  third  day.  Nearly  a  fortnight  later  a  dead  and 
partially  digested  viper  measuring  rather  more  than  twelve 
inches  in  length  was  expelled  by  the  bowel.  The  reptile  was 
identified  as  belonging  to  a  species  the  bite  of  which  excited 
inflammation  but  was  not  fatal. 


CHAPTER  VIII. 
DYSPEPSIA  IN  INFANCY  AND  OLD  AGE. 

Disorders  of  digestion  are  exceptionally  common  at  the 
extremes  of  life.  The  stomach  of  the  new-born  infant  is  an  or- 
gan of  such  limited  capacity  and  of  so  little  physiological  impor- ,; 
tance  that  the  processes  of  digestion  and  absorption  are  carried  i 
out  almost  entirely  by  the  intestines.  It  consequently  happens 
that  if  the  intestinal  functions  become  deranged  from  any 
cause  the  bowel  symptoms  take  precedence  of  those  arising 
from  the  coexisting  disorder  of  the  stomach,  and  in  many 
instances  completely  mask  them.  It  is  only  after  the 
completion  of  the  first  dentition  that  the  intestine  becomes 
gradually  replaced  by  the  stomach  as  the  predominant  factor 
in  the  maintenance  of  the  nutrition. 

About  the  age  of  fifty-five  an  increased  Hability  to  certain 
forms  of  dyspepsia  once  more  manifests  itself,  and  the  com- 
plaint, when  once  established,  usually  proves  very  intractable 
and  not  infrequently  endures  for  the  rest  of  life.  The  remark- 
able failure  of  digestion  exhibited  by  some  elderly  people  is 
sometimes  due  to  degenerative  changes  in  the  tissues  of  the 
stomach  and  bowel,  and  sometimes  to  the  various  diseases  of 
other  important  organs  of  the  body  which  are  particularly  apt 
to  develop  after  middle  life.  The  former  comprise  atrophy  of 
the  mucous  membrane  in  the  pyloric  region,  atony  and  ectasia 
of  the  gastrointestinal  tract,  and  a  gradual  diminution  of  its 
digestive  and  absorptive  powers;  while  among  the  latter,  dis- 
eases of  the  heart,  emphysema  of  the  lungs,  arteriosclerosis 
and  chronic  diseases  of  the  kidneys  exert  the  most  deleterious 
influence  upon  the  digestive  system. 

The  period  of  puberty  is  sometimes  accompanied  by  func- 
tional derangements  of  the  stomach,  the  rapid  growth  of  the 


304  THE   CHRONIC   GASTROENTERITIS    OF   INFANCY. 

body  in  boys  being  often  attended  by  atony  of  the  digestive 
organs  or  by  neurasthenia  gastrica,  while  in  girls,  the  establish- 
ment of  the  catamenia  is  sometimes  associated  with  anaemia 
and  its  attendant  troubles  of  hyperacidity  and  gastric  hyperaes- 
thesia.  Many  women  also  suffer  from  troublesome  indigestion 
at  the  climacteric,  as  the  result  either  of  excessive  loss  of  blood  or 
of  the  profound  nervous  disturbance  which  occurs  at  that  time. 
In  these  latter  cases,  however,  the  resultant  dyspepsias  differ 
in  no  way  from  similar  disorders  met  with  at  other  periods  of 
adult  life,  and  therefore  require  no  additional  description. 

(i)  THE  CHRONIC  GASTROENTERITIS  OF  INFANCY. 
(Chronic  Inflammatory  Diarrhoea — Marasmus — Infantile  Atrophy.) 

Many  terms  have  been  employed  at  different  times  to 
describe  a  chronic  disease  of  infancy  characterized  by  vomiting, 
diarrhoea,  or  some  other  symptom  of  disordered  digestion,  and 
attended  by  gradual  wasting  of  the  tissues  of  the  body.  As  a 
rule,  the  choice  of  nomenclature  has  been  determined  by  the 
predominance  of  some  particular  symptom  of  the  complaint, 
so  that  we  find  such  apparently  diverse  terms  as  "chronic 
vomiting,"  "inflammatory  diarrhoea,"  "athrepsia,"  and  "maras- 
mus," applied  to  the  same  disease,  according  as  one  or  other  of 
its  symptoms  happens  to  be  most  prominent.  But  however 
widely  the  various  cases  may  differ  among  themselves  in  their 
clinical  aspect,  they  all  present  one  common  feature  after 
death,  for  in  every  instance  the  signs  of  chronic  inflammation 
of  the  stomach  and  intestines  with  more  or  less  atrophy  of  the 
mucous  membrane  of  the  alimentary  canal,  can  be  demon- 
strated by  the  microscope.  It  appears,  therefore,  to  be 
justifiable,  as  well  as  expedient,  to  group  all  the  cases  which 
exhibit  this  primary  lesion  into  one  class,  and  to  designate  the 
disease  "chronic  gastroenteritis." 

Etiology. — Chronic  catarrh  of  the  stomach  and  intestine  is 
predisposed  to  by  the  same  conditions  which  render  children 
vulnerable  to  the  acute  form  of  the  disease.     Thus,  congenital 


ETIOLOGY.  305 

syphilis,  rickets,  tuberculosis,  anaemia,  and  malnutrition,  all 
favour  the  chronicity  of  the  digestive  disorder  when  once  it  has 
been  excited;  while  overcrowding,  defective  ventilation, 
deficient  or  deleterious  foods,  or  a  previous  attack  of  intestinal 
catarrh  eminently  predispose  to  the  acquisition  of  the  more- 
enduring  form.  Among  the  exciting  causes  of  the  disease, 
the  habitual  administration  of  unsuitable  food,  exposure  to- 
cold,  or  an  attack  of  an  acute  specific  fever  are  of  the  first 
importance.  Chronic  gastroenteritis  in  infancy  must  con- 
sequently be  regarded  as  essentially  a  preventable  disease, 
inasmuch  as  the  chief  factors  in  its  causation  consist  of  a 
constant  neglect  either  of  the  elementary  laws  which  should 
govern  the  diet  and  hygiene  of  early  life  or  of  those  minor 
disorders  of  digestion  which  usually  precede  the  development 
of  the  complaint.  With  these  facts  in  mind,  it  is  hardly  a 
matter  for  wonder  that  the  disease  is  so  disproportionately 
common  among  the  poor  inhabitants  of  large  cities,  whose 
children  are  exposed  not  only  to  the  dangers  arising  from 
insufficient  nourishment,  but  also  to  those  engendered  by 
the  ignorant  and  superstitious  practices  current  among 
uneducated  persons.  Such  people  invariably  cherish  the 
delusion  that  palatable  substances  and  food  are  synonymous 
terms,  and  it  is  impossible  to  convince  them  that  the  mere 
introduction  of  food  into  the  stomach  is  quite  valueless  for  the 
purposes  of  nutrition,  unless  the  infant  is  capable  of  digesting 
and  assimilating  it. 

Among  1,000  consecutive  cases  of  disease  in  children  which 
came  under  my  notice  at  the  EveHna  Hospital,  172,  or  17.2 
per  cent.,  were  found  to  be  suffering  from  gastroenteritis, 
the  symptoms  of  which  had  existed  for  more  than  a  month. 
From  this  number  I  have  taken,  without  selection,  the  notes 
of  100  cases  of  the  disease,  and  upon  the  analysis  of  these 
the  following  remarks  are  based.  In  only  eight  instances  out 
of  the  entire  number  were  the  infants  fed  entirely  upon  the 
breast,  the  remaining  ninety-two  receiving  either  cow's  milk  or 


3o6 


THE   CHRONIC   GASTROENTERITIS    OF  INFANCY. 


some  kind  of  farinaceous  food.  These  figures  emphasize  in  a 
striking  manner  the  influence  of  diet  in  the  causation  of  the 
chronic  inflammatory  disease.  In  eleven  cases  the  complaint 
was  stated  to  have  followed  immediately  upon  an  attack  of 
some  specific  infectious  fever,  of  which  pertussis,  measles,  and 
scarlatina  were  the  most  important.  Upon  this  point  the 
observations  of  Rilliet  and  Barthez  are  noteworthy,  since 
they  show  that,  among  140  cases  of  chronic  diarrhoea  in  chil- 
dren, twenty-seven  were  preceded  by  pneumonia,  thirty-seven 
by  measles,  seventeen  by  smallpox,  scarlatina,  or  enteric  fever, 
and  twenty-nine  by  either  angina,  pleurisy,  bronchitis,  or  croup. 
With  regard  to  the  importance  of  exposure  to  cold  as  an  ex- 
citing cause  of  the  disease,  I  can  offer  no  reliable  statistics, 
since  in  out-patient  practice  it  is  impossible  to  discriminate 
between  the  influence  of  atmospheric  conditions  and  the  effects 
of  those  dietetic  errors  which  constitute  such  an  extremely 
common  and  important  factor  in  the  production  of  all  diseases 
of  infancy.  There  can  be  no  doubt,  however,  that  an  attack 
of  acute  gastric  or  intestinal  catarrh  can  be  excited  in  the  first 
instance  by  exposure  to  cold,  and  afterward  converted  into  the 
subacute  or  chronic  form  by  the  influence  of  one  of  the  above- 
mentioned  causes.  The  various  ages  at  which  chronic  gastro- 
intestinal catarrh  is  most  commonly  contracted  is  a  matter  of 
some  importance,  and  the  cases  at  my  disposal  allow  of  ar- 
rangement in  the  following  manner: 


Age  of  infant  at 

No.  of 

Breast  and 

Artificial 

commencement 

Breast-fed 

artificial 

foods 

of  disease 

foods 

only 

1-4  months 

34 

I 

I 

32 

4-  8      •; 

10 

I 

7 

2 

8-12 

17 

3 

4 

10 

12-18 

26 

2 

0 

24 

18-24 

13 

I 

0 

12 

100 

8 

12 

80 

ETIOLOGY.  307 

These  figures  present  several  points  of  interest.  It  will 
be  seen  at  once  that  the  disease  is  most  common  within  the 
first  four  months  of  life,  since  no  less  than  34  per  cent,  of 
the  cases  occurred  in  infants  of  this  age.  During  the  next 
four  months  the  cases  only  represent  10  per  cent,  of  the  entire 
number;  but  from  the  eighth  to  the  eighteenth  month  the 
susceptibility  to  the  disease  appears  to  increase,  for  we  find  that 
43  per  cent,  of  all  the  cases  which  came  under  observation 
were  infants  between  eight  and  eighteen  months  old.  After 
the  eighteenth  month  the  complaint  becomes  comparatively 
rare,  and  is  seldom  encountered  after  the  third  year  of  life. 
This  curious  fluctation  in  the  incidence  of  the  disease  at  different 
periods  of  infantile  life  can  only  be  explained  by  an  examination 
of  the  kinds  of  food  which  were  employed  in  the  various  cases 
prior  to  the  onset  of  the  inflammatory  complaint.  Thus, 
among  the  thirty-four  cases  occurring  in  children  less  than 
four  months  old,  thirty-three,  or  97  per  cent.,  were  habitually 
supplied  with  some  form  of  artificial  food,  and  only  in  one 
instance  was  the  child  fed  exclusively  upon  the  breast.  In 
every  instance  the  infant  had  appeared  to  be  perfectly  healthy 
at  birth,  but  within  a  short  time  had  commenced  to  exhibit 
the  symptoms  of  chronic  dyspepsia  or  to  suffer  from  attacks 
of  subacute  catarrh  of  the  stomach  and  intestine,  accompanied 
by  gradual  wasting  of  the  tissues  of  the  body.  It  is  probable, 
therefore,  that  the  chief  cause  of  chronic  gastrointestinal 
catarrh  at  this  period  is  to  be  found  in  the  injudicious  admin- 
istration of  artificial  foods  in  lieu  of  the  maternal  milk. 

The  comparative  immunity  from  the  disease  which  is 
apparent  between  the  fourth  and  ninth  months  of  life  is 
probably  due  to  the  fact  that  at  this  period  the  majority  of 
the  children  are  either  nourished  entirely  upon  the  breast,  or, 
having  escaped  the  initial  dangers  of  artificial  feeding,  are  able 
to^take  the  bottle  with  impunity.  But  about  the  ninth  month 
the  common  custom  of  supplementing  the  breast  milk  with 
biscuits,  cornflour,  or  some  other  variety  of  farinaceous  food 


308  THE   CHRONIC   GASTROENTERITIS    OF  INFANCY. 

at  once  exposes  the  infant  to  the  dangers  arising  from  the 
administration  of  artificial  foods,  and  consequently  the  disease 
once  more  becomes  prevalent  until  the  time  when  milk  is 
finally  discarded  for  the  mixed  diet  of  adult  life.  Among  the 
wealthier  classes,  on  the  other  hand,  mothers  who  nurse  their 
children  are  in  the  habit  of  employing  some  form  of  artificial 
food  about  the  fourth  month,  so  that,  had  these  statistics  been 
compiled  from  observations  made  in  private  practice,  it  is 
probable  that  the  disease  would  have  appeared  to  be  more 
rife  within  the  first  six  months  than  at  any  other  time. 

Morbid  Anatomy. — As  in  the  case  of  every  other  disease 
of  the  digestive  canal,  the  naked-eye  appearances  presented 
by  the  tissues  after  death  are  usually  quite  insignificant  when 
contrasted  with  the  violence  of  the  symptoms  observed  during 
life.  The  stomach  and  small  intestine  are  usually  somewhat 
distended  with  gas,  and  occasionally  the  transverse  colon  and 
sigmoid  flexure  are  also  much  inflated.  The  stomach  in- 
variably shows  signs  of  dilatation,  the  exact  degree  of  enlarge- 
ment varying  directly  with  the  duration  of  the  disease  and  the 
severity  of  the  organic  changes  which  have  occurred  in  the  coats 
of  the  organ.  As  a  rule,  the  lower  border  of  the  viscus  seldom 
extends  more  than  a  finger's  breadth  below  the  level  of  the  um- 
bihcus,  the  enormous  dilatation  which  so  often  accompanies  the 
chronic  gastric  catarrh  of  pulmonary  tuberculosis  being  never 
observed.  When  the  stomach  of  an  infant  becomes  dilated 
owing  to  weakness  of  its  muscular  walls,  the  shape  it  assumes 
diSers  from  that  which  is  observed  under  similar  conditions 
in  adult  hfe.  In  the  majority  of  cases,  it  still  maintains  its 
cyhndrical  form,  owing  to  the  cardiac  and  pyloric  portions 
of  the  organ  participating  equally  in  the  dilatation.  Occasion- 
ally, however,  the  fundus  is  greatly  distended,  while  the 
pyloric  region  still  preserves  its  natural  contour,  and  in  such 
cases  the  lower  end  of  the  oesophagus  is  usually  dilated,  and 
appears  to  pass  imperceptibly  into  the  upper  border  of  the 
stomach.     Some  v/riters  have  described  a  form  of  hour-glass 


MORBID   ANATOMY.  309 

dilatation  of  the  stomach  in  infancy,  but  this  variety  I  have 
never  observed.  In  all  cases  where  the  stomach  is  dilated, 
the  increased  weight  of  the  organ  drags  the  pylorus  down- 
ward and  inward  toward  the  median  line  of  the  abdomen, 
thereby  causing  it  to  describe  an  arc  of  a  circle,  the  centre  of 
which  is  situated  at  the  oesophageal  opening  of  the  diaphragm. 
Upon  opening  the  organ  and  removing  the  thick  layer  of 
mucus  which  adheres  to  its  inner  surface,  the  mucous  mem- 
brane is  found  to  present  a  dead  white,,  opaque  appearance, 
and  to  be  more  firmly  adherent  to  the  subjacent  layers  of 
tissue  than  under  normal  circumstances.  Postmortem  diges- 
tion is  rarely  encountered.  In  long-standing  cases,  where  the 
body  has  undergone  great  emaciation,  the  coats  of  the  stomach 
and  intestines  are  sometimes  so  extremely  thin  and  transparent 
as  to  closely  resemble  tissue-paper.  Vascular  injection  is 
usually  absent,  but  should  an  attack  of  subacute  catarrh  have 
occurred  shortly  before  death,  the  surface  may  exhibit  a  patchy 
or  arborescent  form  of  congestion.  In  very  chronic  cases  the 
mucous  membrane  in  the  pyloric  region  sometimes  presents 
a  rudimentary  form  of  mammillation,  being  mapped  out  into 
small  polygonal  areas  of  thickened  and  opaque  tissue.  In 
other  instances,  the  secretory  membrane  exhibits  a  brownish 
or  slate-coloured  tinge  as  a  result  of  chronic  congestion,  or 
minute  extravasations  of  blood  may  be  observed  in  the  cardiac 
region  of  the  organ  or  in  the  vicinit}-  of  the  lesser  curvature. 
Haemorrhagic  erosions  are  also  frequently  encountered  in  the 
cardiac  extremity  of  the  stomach,  but  the  follicular  form  of 
ulceration  due  to  disease  of  the  solitary  glands  is  rare,  unless 
the  primary  complaint  has  been  complicated  with  tuberculosis. 
Parrot  and  other  writers  have  described  aphthous  patches 
upon  the  mucous  membrane  similar  to  those  which  occur  in  the 
mouth,  as  weU  as  the  occasional  formation  of  a  false  membrane 
like  that  observed  in  cases  of  diphtheria  of  the  stomach.  The 
former  condition  is,  however,  extremely  rare;  the  latter  I  have 
never  seen  in  cases  of  simple  chronic  gastritis. 


3IO  THE   CHRONIC   GASTROENTERITIS   OF   INFANCY. 

The  small  intestine  seldom  exhibits  any  more  decided 
appearances  of  disease  than  those  already  noted.  The 
Peyer's  patches  are  apt  to  be  enlarged  in  the  early  stages  of  the 
complaint,  and  often  present  signs  of  congestion  or  even 
minute  haemorrhages.  Ulceration  seldom  occurs,  but  as  the 
disease  progresses  an  atrophy  of  the  lymphoid  tissue  takes 
place.  The  lower  portion  of  the  ileum,  within  an  inch  or  two 
of  the  ileo-caecal  valve,  is  occasionally  the  seat  of  an  irregular 
form  of  ulceration,  superficial  in  character,  and  not  infre- 
quently multiple.  The  mucous  membrane  in  the  immediate 
neighbourhood  of  the  disease  is  thickened  and  pigmented  from 
chronic  inflammation. 

In  all  cases  of  chronic  enteritis,  the  most  character- 
istic phenomena  are  to  be  found  in  the  large  bowel, 
especially  near  its  lower  end.  Here  thickening  and  adhesion 
of  the  mucous  membrane  to  the  muscular  coat  is  the  rule, 
and  in  most  cases  the  superficial  aspect  of  the  inner  coat 
presents  a  mottled  appearance,  owing  to  the  presence  of  an 
immense  number  of  minute  points  of  pigmentation.  In  the 
transverse  colon  and  caecum  this  feature  is  sometimes  so 
marked  that  areas  of  the  mucous  membrane  several  inches  in 
extent  exhibit  a  uniform  slate-coloured  tinge.  This  condition 
is  quite  distinct  from  the  superficial  staining  which  results 
from  the  long-continued  use  of  bismuth  or  arsenic.  In  about 
62  per  cent,  of  the  cases  where  the  disease  has  existed  for  more 
than  four  weeks,  the  large  intestine  is  affected  with  follicular 
ulceration,  the  severity  of  which  varies  with  the  degree  and 
duration  of  the  inflammatory  process.  In  mild  cases,  the 
inner  surface  of  the  colon  and  rectum  exhibits  numerous  small 
pits,  separated  from  one  another  by  patches  of  congested 
tissue,  while  in  more  severe  instances,  necrosis  of  the  solitary 
follicles  occurs,  and  gives  rise  to  definite  circular  ulcers,  which 
coalesce  and  ultimately  involve  a  considerable  area  of  the 
mucous  membrane.  These  ulcers  usually  have  their  bases 
situated  in  the  submucous  coat,  but  occasionally  they  penetrate 


Fig.  7. — Section  of  a  Normal  Infant's  Stomach.      (  x  80.) 


Fig.  7a. — Section  of  the  Stomach  in  an  Early  Case  of  Gastro-enteritis,  showing 
the  Infiltration  of  Round  Cells  between  the  Glands  of  the  Mucous  Mem- 
brane (first  stage  of  the  disease),      (x  80.) 


MORBID   HISTOLOGY.  3 II 

deeply  into  the  muscular  tunic,  and  may  even  lay  bare  the 
serous  covering  of  the  bowel.  In  very  chronic  cases  the  inner 
surface  of  the  colon,  sigmoid  flexure,  and  rectum  may  be 
completely  honeycombed  by  the  ulcerative  process,  the  only 
remains  of  mucous  membrane  to  be  observed  consisting  of  a 
network  of  indurated  and  discoloured  tissue  which  serves  to 
separate  the  various  ulcers  from  one  another.  As  a  rule,  the 
lower  end  of  the  large  intestine  suffers  more  severely  than  the 
upper  portion,  while  in  some  cases  the  rectum  is  the  only  part 
of  the  bowel  affected  by  ulceration. 

Morbid  Histology. — The  earliest  description  of  the 
histological  appearances  presented  by  the  stomach  and 
intestines  in  cases  of  "infantile  atrophy"  is  to  be  found  in  the 
writings  of  Parrot,  who  recognised  the  signs  of  chronic  inflam- 
mation in  many  of  the  specimens  which  he  examined  with  the 
microscope.  Since  these  observations  were  published,  the 
subject  has  attracted  comparatively  little  attention,  and  most 
writers,  while  they  admit  the  presence  of  chronic  gastro- 
enteritis, appear  to  attach  but  Httle  importance  to  the  organic 
changes  induced  in  the  digestive  tissues  by  the  inflammatory 
disease.  Several  years  ago,  being  then  unaware  of  Parrot's 
monograph  on  athrepsia,  I  commenced  a  systematic  exam- 
ination of  the  digestive  organs  of  children  dying  from  different 
forms  of  disease.  Among  these  were  sixteen  cases  of  infants 
who  had  succumbed  to  progressive  emaciation,  and  in  whom 
postmortem  examination  threw  no  light  whatever  upon  the 
cause  of  the  fatal  symptoms.  But  in  every  instance  the 
microscope  demonstrated  the  presence  of  organic  changes  of 
an  important  nature  in  the  alimentary  tract,  and  it  is  chiefly 
from  these  cases  that  the  following  remarks  concerning  the 
morbid  histology  of  the  disease  have  been  compiled. 

The  Stomach. — The  first  sign  of  disease  in  the  stomach 
consists  of  an  infiltration  of  round  cells  into  the  interstitial 
connective  tissue  of  the  mucous  membrane  similar  to  that 
already  described  in  cases  of  acute  gastritis.     The  chief  seat 


312  THE    CHRONIC    GASTROENTERITIS    OF    INFANCY. 

of  the  mischief  is  situated  between  the  ducts  of  the  gastric 
glands  just  beneath  the  superficial  epithelium,  the  columnar 
cells  of  which  are  either  detached  or  else  converted  into  goblet 
cells.  As  the  disease  progresses,  the  inflammatory  process 
extends  in  the  direction  of  the  muscularis  mucosas,  so  that 
eventually  the  whole  of  the  tissue  between  the  glands  becomes 
densely  packed  with  deeply-staining  nuclei,  among  which  the 
original  connective-tissue  elements  can  often  be  discerned  in  a 
state  of  active  proliferation. 

The  engorgement  of  the  capillary  vessels  which  ramify 
in  the  mucous  membrane  increases  the  pressure  already 
exerted  upon  the  tubules,  so  that  the  latter  become  displaced 
and  their  outlines  obscured.  The  solitary  lymphatic  glands 
also  undergo  an  increase  in  size  owing  to  the  proliferation  of 
their  cellular  elements,  and  tend  to  encroach  upon  the  free 
surface  of  the  mucous  membrane. 

The  second  stage  of  the  process  is  marked  by  the  gradual 
organization  of  the  inflammatory  products.  The  superficial 
epithelium  is  now  completely  detached,  and  the  surface  of 
the  section  exhibits  a  jagged  and  iineven  appearance  owing 
to  the  irregular  contraction  of  the  newly  formed  fibrous  tissue. 
Instead  of  pursuing  a  course  perpendicular  to  the  surface,  the 
ducts  of  the  glands  are  seen  to  be  twisted  and  distorted  by  the 
pressure  exercised  upon  them,  while  their  lumina  are  often 
choked  with  mucus,  detached  ceUs,  and  epithelial  debris. 
The  tubular  glands  themselves  are  separated  from  one  another 
by  strands  of  fibrous  tissue,  the  thickness  of  which  varies  at 
different  spots.  The  basement  membrane  of  the  glands  is 
thickened,  and  the  secretory  epithelium  undergoes  a  series  of 
changes  as  a  result  of  the  interference  with  its  nutrition.  In 
the  cardiac  two-thirds  of  the  stomach,  where  the  tubular 
glands  are  straight  and  comparatively  short,  the  peptic  cells 
usually  proliferate  at  first,  and  entirely  block  the  lumen  of  the 
gland.  Subsequently  they  undergo  fatty  degeneration,  so  that 
eventually  it  is  impossible  to  distinguish  the  outlines  of  the 


Fig.  8. — Photomicrograph  of  the  Stomach  in  a  Case  of  Chronic  Gastro-enteritis, 
showing  the  Formation  of  Fibrous  Tissue  between  the  Gastric  Glands 
(second  stage  of  the  disease),      (x  80.) 


Fig.  8a.— Photomicrograph  of  the  Stomach  in  a  Case  of  Chronic  Gastro-enteritis, 
showing  Cirrhosis  of  the  Mucous  Membrane,  with  Complete  Atrophy  of  the 
Gastric  Glands  (third  stage  of  the  disease),     (x  80.) 


MORBID   HISTOLOGY.  313 

various  cells  amongst  the  mass  of  fatty  and  granular  material 
which  fills  the  greater  portion  of  the  tubule.  In  the  pyloric 
region  of  the  organ,  on  the  other  hand,  where  the  gastric 
glands  are  of  much  greater  length,  and  usually  convoluted, 
the  first  effect  of  the  contraction  of  the  interstitial  connective 
tissue  is  to  constrict  some  portion  of  the  tubule,  and  thus  to 
impede  the  evacuation  of  its  secretion.  As  the  result  of  this, 
the  lower  end  of  the  gland  becomes  dilated,  while  its  epithelium 
loses  its  characteristic  features  and  is  gradually  flattened 
against  the  basement  membrane.  In  this  manner  a  retention 
cyst  is  formed  in  the  substance  of  the  mucous  membrane,  which 
eventually  becomes  lined  with  a  single  layer  of  cubical  epithe- 
lium. In  certain  sections,  the  solitary  glands  may  be  observed 
to  have  discharged  their  contents  into  the  cavity  of  the  stomach 
with  the  production  of  a  follicular  ulcer,  while  here  and  there 
a  small  haemorrhage  or  minute  erosion  may  be  discerned  upon 
the  surface  of  the  mucous  membrane.  These  latter  appear- 
ances are,  however,  merely  accidental,  and  are  devoid  of  any 
special  significance. 

At  this  period  of  the  disease  the  submucous  coat  of  the 
organ  often  participates  in  the  inflammatory  condition,  and 
presents  a  general  engorgement  of  its  blood  vessels,  with  a 
considerable  increase  in  the  number  of  nuclei  scattered  through 
its  tissue.  The  muscularis  mucosae  is  also  infiltrated  by 
small  round  cells,  and  in  many  places  the  contractile  fibres 
show  signs  of  compression  by  newly  formed  fibrous  elements. 
The  muscular  coat  of  the  organ  seldom  exhibits  any  morbid 
phenomena  beyond  extreme  engorgement  of  its  vessels  and 
an  increase  in  the  number  of  nuclei  situated  in  its  interstitial 
connective  tissue. 

The  third  and  last  stage  of  the  inflammatory  process  is 
characterized  by  complete  cirrhosis  of  the  mucous  membrane, 
with  secondary  changes  in  the  other  coats  of  the  stomach. 
In  many  cases  the  surface  of  the  section  has  a  peculiar 
papillary  or  villous  appearance,  which  at  first  glance  may 


314  THE    CHRONIC    GASTROENTERITIS    OF    INFANCY. 

cause  the  tissue  to  be  mistaken  for  the  small  intestine.  These 
spurious  villi  are  due  to  the  accumulation  of  the  products  of 
inflammation  between  the  mouths  of  the  ducts,  and  consist 
of  round  and  spindle  cells  with  capillary  vessels  of  new  form- 
ation. The  gradual  contraction  of  the  new  fibrous  tissue 
in  the  substance  of  the  mucous  membrane  has  given  rise  to 
atrophy  of  the  gastric  glands,  so  that  the  greater  part  of 
the  section  appears  to  be  composed  of  fibrous  elements 
among  which  are  scattered  the  remains  of  the  tubules,  the 
cells  of  which  are  usually  in  an  advanced  state  of  fatty  de- 
generation. The  cirrhotic  tissue  is  extremely  vascular,  and 
when  artificially  injected  exhibits  numerous  newly  formed 
vessels.  It  is  probably  on  this  account  that  the  atrophic 
mucous  membrane  presents  so  little  deviation  from  the 
normal  when  viewed  by  the  naked  eye.  At  this  stage  of 
the  complaint  the  muscularis  mucosae  is  more  or  less  completely 
destroyed,  and  the  few  strands  of  muscular  fibres  which 
remain  appear  to  be  embedded  in  a  mass  of  fibrous  tissue, 
and  present  signs  of  fatty  degeneration.  The  submucous 
coat  is  much  thickened  and  condensed  by  the  organization 
of  the  inflammatory  products  effused  into  its  connective 
tissue,  while  the  arterioles  which  pass  obliquely  upward  to 
supply  the  mucous  membrane  exhibit  sclerotic  changes 
in  their  inner  and  middle  tunics,  and  are  not  infrequently 
filled  with  thrombi.  The  muscular  coat  is  often  closely 
intersected  by  bands  of  fibrous  tissue,  and  the  contractile 
fibres  appear  granular  or  fatty.  In  very  chronic  cases 
the  wall  of  the  organ  may  be  reduced  to  almost  one-half  of 
its  normal  thickness.  Although  the  whole  of  the  stomach 
is  usually  involved  in  the  inflammatory  process,  the  disease 
is  found  to  vary  in  severity  at  different  spots.  As  a  rule,  its 
effects  are  most  noticeable  in  the  region  of  the  lesser  curvature, 
where  the  cirrhotic  changes  may  give  rise  to  an  appearance 
of  superficial  scarring.  In  other  parts  of  the  organ  the 
disease  exhibits  a  more  irregular  distribution,  so  that  it  may 


MORBID  HISTOLOGY.  315 

often  be  observed  that,  while  at  one  spot  the  mucous 
membrane  is  already  in  an  advanced  state  of  cirrhosis,  at 
another  in  the  immediate  neighbourhood  the  inflammatory- 
disease  has  only  attained  the  second  stage.  These  facts  will 
be  referred  to  later,  when  the  question  of  recovery  is  discussed. 

The  Small  Intestine. — The  small  intestine  presents  the 
same  general  appearances  as  have  already  been  described  in 
the  case  of  the  stomach.  The  vascular  injection  which 
accompanies  the  first  stage  of  the  disease  is  associated  with 
an  infiltration  of  small  round  cells  into  the  interstitial  con- 
nective tissue  of  the  villi,  and  into  that  which  separates  the 
glands  of  Lieberkiihn  from  one  another.  When  organization 
of  the  exudation  takes  place,  the  contraction  of  the  fibrous 
tissue  obliterates  the  glandular  structures,  so  that  in  severe 
cases  the  mucous  membrane  becomes  more  or  less  completely 
cirrhosed  (Fig.  9). 

At  an  early  period  in  the  disease  the  columnar  epithelium 
which  normally  covers  the  surface  of  the  bowel  is  detached, 
and  many  of  the  villi  become  adherent  to  one  another  as  a 
result  of  the  inflammation  of  their  structure.  Thus,  in  some 
sections,  the  surface  of  the  mucous  membrane  presents  a 
series  of  hoops  or  arches,  owing  to  the  adhesion  of  the  villi  at 
their  free  extremities,  while  in  others  the  distinctive  features 
of  the  tissue  are  obliterated  through  agglutination  of  the 
contiguous  villi  by  their  lateral  margins.  In  many  cases  the 
epithelium  of  the  tubular  glands  desquamates,  and  the  ducts 
become  blocked  by  masses  of  granular  or  fatty  material; 
but  in  others  the  cells  of  Lieberkiihn's  glands  preserve  their 
normal  appearance  throughout.  As  soon  as  the  contraction 
of  the  interstitial  tissue  exerts  pressure  upon  the  ducts  of  the 
glands,  the  tubules  commence  to  dilate,  and  are  eventually 
converted  into  small  retention  cysts,  similar  in  structure  to 
those  already  described  in  the  case  of  the  stomach.  Brunner's 
glands,  on  the  other  hand,  appear  for  the  most  part  to  escape 
the  results  of  retention  of  their  secretion,  but  fatty  degeneration 


3l6  THE    CHRONIC    GASTROENTERITIS    OF    INFANCY. 

of  the  epithelium  of  these  convoluted  tubules  is  frequently- 
observed  before  the  disease  in  the  mucous  membrane  has 
advanced  beyond  the  initial  stage.  At  a  later  period  of  the 
complaint,  when  considerable  induration  of  the  mucous  and 
submucous  coats  has  taken  place,  the  basement  membrane 
of  Bnmner's  glands,  as  well  as  the  connective  tissue  between 
them,  becomes  remarkably  thickened,  and  the  secretory 
epithelium  degenerates  and  is  detached. 

The  Large  Intestine. — In  the  large  intestine  the  chief  signs 
of  disease  are  to  be  found  in  the  transverse  and  descending 
portions  of  the  colon  and  in  the  rectum.  The  superficial 
epithelium  usually  persists  for  a  considerable  time,  and  its 
columnar  cells  may  often  be  recognised,  in  a  degenerated  con- 
dition, upon  the  surface  of  the  mucous  membrane,  when  the 
latter  is  already  in  an  advanced  state  of  disease.  As  a  rule, 
the  inflammatory  process  is  most  pronounced  in  the  centre 
of  the  mucous  coat  of  the  bowel,  so  that  when  fibrous  tissue 
forms  the  tubular  glands  appear  to  be  divided  through  the 
middle  by  a  fibrous  band.  The  epithelium  lining  the  ducts  is 
partially  transformed  into  cells  of  the  goblet  type;  while  the 
rest  becomes  detached  and  forms  fatty  and  granular  plugs, 
which  are  gradually  extruded  from  the  mouths  of  the  glands 
by  the  mechanical  pressure  of  the  inflammatory  exudation 
(Fig.  lo) .  When  the  products  of  inflammation  undergo  organi- 
zation, the  tubular  glands  become  constricted  about  their 
centres  and  their  fundi  are  eventually  converted  into  flask- 
shaped  retention  cysts.  In  the  last  stage  of  the  disease  the 
whole  of  the  mucous  and  submucous  coats  of  the  bowel  are 
completely  cirrhosed.  Occasionally  the  columnar  cells  lining 
an  apparently  healthy  gland  are  observed  to  contain  a  quantity 
of  golden-yellow  pigment,  as  though  they  were  in  the  act  of 
excreting  some  product  of  blood  disorganization.  In  very 
chronic  cases  large  thin-walled  vessels  may  often  be  seen 
coursing  through  the  cirrhotic  tissue  and  forming  sinuses  of 
considerable  size  close  to  the  free  surface  of  the  diseased  bowel. 


Pig.  9. — Photomicrograph  of  the  Small  Intestine  in  a  Case  of  Chronic  Gastro- 
enteritis, showing  Cirrhosis  of  the  Mucous  Membrane,  wilh  Alrophy  of  the 
Glands.      ( x  80.) 


Fig.  10. — Photomicrograph  of  the  Large  Intestine  in  a  Case  of  Chronic  Gastro- 
enteritis, showing  Partial  Destruction  of  the  Glands  of  the  Mucous  Mem- 
brane.    ( X  80.) 


MORBID   HISTOLOGY.  317 

This  remarkable  vascularity  of  the  newly-formed  fibrous  tissue 
is  probably  the  cause  of  the  haemorrhage  which  so  often  occurs 
at  each  act  of  defaecation. 

Among  the  organic  changes  in  other  viscera  which  are  apt 
to  be  associated  with  chronic  gastroenteritis,  disease  of  the 
kidney  is,  perhaps,  the  most  important.  In  his  excellent 
monograph  upon  "athrepsia,"  Parrot  describes  three  morbid 
conditions  of  the  renal  organs  which  he  had  encountered  in 
cases  of  infantile  atrophy :  fatty  degeneration  (steatose) ,  throm- 
bosis of  the  renal  veins,  and  deposition  of  urate  of  sodium  in 
the  substance  of  the  organ. 

Fatty  degeneration  of  the  kidney  is  of  comparatively  rare 
occurrence.  When  it  exists,  the  organ  is  slightly  increased  in 
size,  and  presents  a  pale  yellow  or  mottled  appearance,  after 
the  capsule  has  been  removed.  The  cortex  is  increased  in 
thickness,  and  at  its  periphery  and  near  the  apex  of  the  pyra- 
mids yellow  striae  may  often  be  observed.  Under  the  micro- 
scope the  vessels  of  the  Malpighian  bodies  are  found  to  be 
engorged,  while  the  walls  of  the  glomeruli  exhibit  an  excess  of 
nuclei.  The  first  sign  of  disease  consists  of  an  increased  opacity 
of  the  protoplasm  of  the  columnar  epithelium,  which  gradually 
resolves  itself  into  a  large  number  of  minute  granules.  These 
coalesce  to  form  refractile  droplets  of  some  size,  which  stain 
black  with  osmic  acid,  and  finally  accumulate  in  such  numbers 
as  to  completely  block  the  tubules. 

Chronic  parenchymatous  nephritis  has  been  described  by 
certain  writers  as  a  frequent  complication  of  chronic  catarrh 
of  the  gastrointestinal  tract  in  infancy,  but  in  only  one  of  the 
seventeen  cases  which  I  especially  examined  with  reference 
to  this  point  did  the  tubules  show  any  signs  of  inflammation; 
while  Holt  only  detected  renal  disease  in  one  case  among  the 
series  he  investigated. 

Thrombosis  of  the  renal  veins  is  usually  confined  to  cases 
of  a  very  chronic  and  severe  nature.  When  it  exists,  the  kid- 
ney is  found  to  be  enlarged  and  its  capsule  tense.     Scattered 


3l8  THE   CHRONIC   GASTROENTERITIS    OF   INFANCY. 

over  the  surface  of  the  organ  are  numerous  small  areas  of  a 
purple  colour,  which  upon  section  are  found  to  extend  for 
some  distance  into  the  substance  of  the  viscus.  The  apices 
of  the  pyramids  are  also  deeply  congested,  and  exhibit  a  blue 
or  black  colouration.  The  medium-sized  branches  of  the  renal 
veins  are  filled  with  greyish-white  antemortem  clot,  while 
the  larger  veins  usually  contain  coagula  of  recent  formation. 
In  rare  instances  the  thrombosis  may  extend  as  far  as  the 
entrance  of  the  renal  veins  into  the  inferior  vena  cava.  Capil- 
lary haemorrhages  upon  the  surface  or  into  the  tissues  of  the 
kidney  are  often  observed,  and  in  a  considerable  proportion 
of  the  cases  an  apoplectic  condition  of  the  adrenals  may  also 
be  detected  (Parrot,  Valleix,  Mattel). 

Uratic  concretions  in  the  tubules  of  the  kidney  are  by  no 
means  uncommon.  As  a  rule,  they  take  the  form  of  yellowish- 
red  masses,  situated  near  the  apices  of  the  pyramids,  which 
shade  off  into  the  substance  of  the  organ  in  fan-shaped  lines 
of  a  pale  yellow  colour.  Occasionally  the  calyces,  and  even 
the  mucous  membrane  of  the  pelvis,  are  found  to  be  thickly 
powdered  over  with  amorphous  urates. 

When  examined  with  the  microscope,  the  straight  tubules 
are  found  to  be  blocked  by  opaque  granular  cylinders,  which 
under  a  high  power  are  seen  to  be  composed  of  a  vast  number 
of  minute  spherical  crystals.  Considerable  discussion  has 
taken  place  concerning  the  exact  chemical  composition  of 
these  crystalline  deposits,  Virchow  maintaining  that  they 
consist  of  urate  of  ammonium,  while  other  authorities  (Parrot, . 
West)  consider  them  to  be  either  uric  acid  or  urate  of  sodium. 
It  is  probable  that  in  the  majority  of  cases  the  sodic  salt  is  the 
chief  constituent  of  the  deposit. 

Legendre  was  the  first  to  show  that  fatty  degeneration  of 
the  liver  is  a  frequent  result  of  chronic  diarrhoea  in  children. 
In  this  condition  the  organ  is  seldom  notably  enlarged,  but 
presents  an  anaemic  appearance,  while  its  tissue  is  extremely 
soft  and  friable.     Under  the  microscope  the  cells  in  the  outer 


MORBID   HISTOLOGY.  319 

zone  of  each  lobule  are  seen  to  contain  a  large  number  of  fat 
globules.  Occasionally  I  have  observed  the  muscle  of  the 
heart  to  present  similar  features,  the  musculi  papillares  of  the 
left  ventricle  being,  as  a  rule,  the  first  portion  of  the  organ 
to  suffer.  This  fatty  degeneration  of  the  heart  is  possibly  the 
cause  of  the  sudden  and  fatal  syncope  which  sometimes  occurs 
in  cases  of  chronic  gastrointestinal  catarrh,  and  may  also  be 
responsible  for  the  mitral  systolic  bruit  which  occasionally 
develops  during  the  later  stages  of  the  disease. 

In  every  case  where  death  has  occurred  from  gradual 
failure  of  the  heart,  congestion  and  cedema  of  the  lungs  are  found 
at  the  necropsy.  In  most  cases  catarrh  of  the  bronchial  tubes 
also  exists,  associated  with  more  or  less  extensive  lobular 
collapse;  while  in  nearly  16  per  cent,  of  my  fatal  cases  death 
was  directly  attributable  to  an  attack  of  broncho-pneumonia. 

Pulmonary  tuberculosis  is  also  frequently  encountered  at 
the  postmortem  examination,  and  there  can  be  little  doubt 
that  many  infants  who  are  supposed  to  die  from  simple 
bronchitis  in  reality  succumb  to  this  form  of  lung  mischief. 

Capillary  hcsmorrhages  into  the  meninges  or  upon  the 
surface  of  the  brain  are  comparatively  common,  while  in  some 
instances  sanguineous  effusions  of  considerable  size  occur  in 
the  region  of  the  medulla  or  in  the  substance  of  the  cerebrum. 
Parrot  observed  an  effusion  of  blood  in  the  substance  of  the 
brain  in  five  out  of  thirty-four  cases  of  intracranial  haemorrhage. 

Thrombosis  of  the  cerebral  sinuses  is  occasionally  the 
immediate  cause  of  death.  The  anterior  longitudinal  sinus 
is  the  one  which  is  most  commonly  affected,  but  sometimes 
the  lateral  sinuses  or  some  of  the  smaller  veins  situated  in  the 
corpus  striatum  or  upon  the  surface  of  the  brain  are  affected 
in  a  similar  manner. 

Finally,  it  may  be  mentioned  that,  in  a  large  percentage 
of  the  cases  of  chronic  gastroenteritis,  the  bronchial  and 
mesenteric  glands  are  found  after  death  to  be  enlarged  and 
caseous,  and  are  not  infrequently  affected  with  miliary  tubercle. 


320  THE    CHRONIC   GASTROENTERITIS    OF   INFANCY. 

Symptoms. — The  symptoms  of  chronic  gastroenteritis 
usually  commence  in  an  insidious  manner,  and  often 
develop  by  almost  imperceptible  degrees  from  those  which 
accompany  the  antecedent  condition  of  dyspepsia.  When 
the  disease  follows  immediately  upon  an  attack  of  acute 
catarrh  of  the  digestive  tract,  the  urgency  of  the  vomiting  and 
diarrhoea  gradually  abates,  but  the  infant  continues  to  reject 
its  food  at  intervals,  and  to  void  three  or  four  loose  motions 
during  the  course  of  each  day.  These  symptoms  are  accom- 
panied by  anaemia,  fretfulness,  and  a  steady  loss  of  flesh,  and, 
as  a  rule,  also  by  an  elevation  of  the  temperature  at  night. 
Among  the  loo  cases  of  the  disease  to  which  allusion  has 
been  made,  nine  were  stated  to  have  commenced  in  an  acute 
manner,  and  it  is  interesting  to  observe  that  in  four  of  these 
the  complaint  ensued  immediately  after  an  attack  of  measles. 
In  the  remaining  ninety-one  cases  the  disease  followed  chronic 
indigestion,  the  transition  from  one  complaint  to  the  other 
being  unattended  by  any  phenomena  of  sufficient  importance 
to  attract  the  notice  of  the  parents. 

Following  the  teaching  of  Parrot,  it  has  been  the  custom 
to  divide  the  clinical  course  of  the  disease  into  three  stages, 
the  first  of  which  is  characterised  by  the  prominence  of  the 
gastrointestinal  symptoms,  the  second  by  wasting  of  the  tissues, 
and  the  third  by  certain  cerebral  phenomena  indicative  of 
exhaustion.  Although  this  sequence  of  events  may  be  ob- 
served in  many  chronic  cases,  in  a  very  large  number  the 
different  stages  either  run  concurrently  or  even  appear  in 
reverse  order.  Thus,  cases  are  frequently  met  where  pro- 
gressive emaciation  and  anaemia  constitute  the  primary  and 
most  important  symptoms  of  the  malady,  notwithstanding  the 
fact  that  both  the  stomach  and  intestine  are  found  after  death 
to  be  in  an  advanced  state  of  disease.  In  other  cases,  again, 
loss  of  flesh  or  cerebral  symptoms  are  present  from  the  com- 
mencement and  continue  throughout  the  whole  course  of  the 
complaint.     For  these  reasons  I  shall  merely  offer  a  general 


SYMPTOMS.  321 

description  of  the  disease  and  its  complications,  without 
endeavouring  to  draw  any  hard  and  fast  hne  between  its 
different  stages. 

Gastric  and  Intestinal  Symptoms. — Symptoms  indicative 
of  inflammation  of  the  stomach  or  intestine  are  present  in 
every  case  at  one  period  or  another  during  the  course  of  the 
complaint.  As  a  rule,  a  loose  condition  of  the  bowels  or  an 
abnormal  appearance  of  the  stools  is  the  first  symptom  to 
attract  attention.  When  the  chronic  disease  follows  im- 
mediately upon  an  acute  attack,  the  stools  usually  number 
from  four  to  seven  a  day,  and  consist  of  a  dirty  green  or 
muddy  yellow  liquid,  alternating  occasionally  with  others  of  a 
pasty  consistence  and  paler  tint;  but  after  a  time  the  tendency 
is  for  the  motions  to  become  quite  diffluent,  and  to  exhale  an 
intolerable  stench. 

In  the  more  insidious  variety,  on  the  other  hand,  the 
stools  are  passed  less  frequently,  and  exhibit  remarkable 
variations  from  time  to  time  in  their  naked-eye  appearances. 
As  a  rule,  they  are  abnormally  copious,  and  often  seem  to 
exceed  in  volume  the  total  amount  of  nourishment  consumed 
by  the  child.  At  one  time  they  may  consist  entirely  of  a 
pale  grey  and  putty-like  material,  in  which  a  few  lumps  or 
streaks  of  green  are  visible;  while  at  another  they  are  com- 
posed of  a  curdy  or  flaky  substance  tinged  with  green  and 
mixed  with  a  small  quantity  of  fluid.  At  other  times,  again, 
the  dejecta  may  closely  resemble  chopped  spinach;  or  perhaps 
several  ounces  of  a  thin,  opaque  liquid  hke  gruel  may  be 
evacuated  from  the  bowel.  In  every  case  the  motions  possess 
a  most  offensive  odour,  which  clings  obstinately  to  the  napkins 
despite  repeated  washing.  With  the  progress  of  the  disease 
the  stools  become  diminished  in  quantity  and  more  fluid  in 
character,  and  although  even  at  an  advanced  stage  of  the 
complaint  they  may  still  present  a  green  and  curdy  appearance, 
they  more  usually  consist  of  a  brown  and  slimy  material, 
containing  traces  of  blood.     Occasionally  the  infant  habitually 


322  THE    CHRONIC    GASTROENTERITIS    OF    INFANCY. 

voids  a  jelly-like  substance  entirely  composed  of  mucus,  or 
every  stool  contains  a  large  number  of  opaque  pellets  and 
shreds  of  the  same  material. 

Hemorrhage  from  the  bowel  is  by  no  means  infrequent 
in  the  later  stages  of  the  disease,  each  evacuation  being  found 
to  contain  streaks  or  clots  of  bright  blood.  When  the  act  of 
defaecation  is  accompanied  by  tenesmus,  a  small  quantity  of 
liquid  blood  is  often  voided  with  each  motion,  but  in  many 
of  these  cases  the  source  of  the  bleeding  is  to  be  found  in  a 
prolapse  of  the  mucous  membrane  of  the  bowel.  As  a  rule, 
the  frequency  of  the  diarrhoea  varies  inversely  with  the  severity 
of  the  vomiting,  and  when  the  latter  is  a  prominent  symptom 
of  the  case,  the  bowels  may  be  constipated  rather  than  relaxed. 
Sometimes  the  diarrhoea  presents  lienteric  features,  each  meal 
being  immediately  followed  by  the  passage  of  a  stool  consist- 
ing mainly  of  undigested  food.  This  form  of  intestinal  flux 
appears  to  arise  from  an  abnormally  irritable  state  of  the 
bowel,  which  causes  it  to  be  thrown  into  a  violent  contraction  as 
soon  as  food  is  introduced  into  the  stomach.  At  the  commence- 
ment of  the  disease  the  stools  are  invariably  acid  to  litmus- 
paper,  and  contain  an  excess  of  lactic  and  other  organic  acids; 
but  as  the  complaint  progresses  the  dejecta  tend  to  become 
less  acid,  and  in  advanced  cases  they  may  be  either  neutral  or 
even  slightly  alkaline  in  reaction. 

Although  vomiting  is  commonly  supposed  to  accompany 
every  case  of  chronic  gastritis,  it  is  surprising  how  few  infants 
with  the  disease  suffer  from  continued  emesis.  Thus,  only 
44  per  cent,  of  my  cases  exhibited  this  symptom,  notwithstand- 
ing the  fact  that  a  chemical  examination  of  the  gastric  contents 
usually  indicated  the  existence  of  severe  anatomical  changes 
in  the  mucous  membrane  of  the  stomach. 

In  some  cases,  however,  the  infant  vomits  constantly  during 
the  whole  course  of  the  disease,  the  milk  being  rejected  in  a 
curdled  state  almost  as  soon  as  it  is  swallowed.  Even  in  the 
absence  of  food  the  child  may  be  subjected  to  severe  attacks  of 


SYMPTOMS.  323 

retching,  whch  have  for  their  object  the  expulsion  from  the 
stomach  of  small  quantities  of  sticky  mucus.  When  this 
condition  continues  unrelieved,  the  symptoms  of  emaciation 
and  exhaustion  make  rapid  progress,  and  the  case  often  ter- 
minates fatally  within  a  few  weeks.  In  other  instances  vomit- 
ing is  only  of  occasional  occurrence,  unless  it  be  directly  pro- 
voked by  overloading  the  stomach  with  food. 

All  cases  are  liable  to  suffer  from  intercurrent  attacks  of 
subacute  gastritis,  which  usually  persist  for  three  or  four  days, 
and  are  accompanied  by  severe  vomiting,  and  by  rapid  wasting 
of  the  tissues. 

Pain  in  the  abdomen  is  experienced  in  almost  every  case 
at  one  time  or  another  during  the  course  of  the  disease.  It  is 
most  common  at  an  early  stage,  before  the  diarrhoea  has  become 
fully  established,  and  usually  subsides  to  a  great  extent  as  soon 
as  the  motions  assume  a  liquid  character.  The  symptom  is  of  a 
coHcky  nature,  and  arises  from  the  presence  of  irritant  mate- 
rials or  gas  within  the  inflamed  bowel.  In  cases  of  lienteric 
diarrhoea,  sudden  and  severe  griping  in  the  umbilical  or  hypo- 
gastric region  precedes,  and  perhaps  accompanies,  each  action 
of  the  bowels.  The  infant  expresses  its  sense  of  the  abdominal 
discomfort  by  constant  contraction  of  the  muscles  of  the  fore 
head  and  face,  spasmodic  flexion  of  the  legs  and  thighs,  and 
by  frequent  twistings  and  writhings  of  the  body.  In  long- 
standing and  neglected  cases  the  flexor  muscles  of  the  lower 
limbs  become  permanently  contracted,  so  that  it  is  impossible 
to  straighten  the  legs  without  the  use  of  an  anaesthetic. 

General  Symptoms. — After  the  lapse  of  a  period  of  time, 
which  varies  with  the  severity  of  the  digestive  disorder,  the 
child  commences  to  lose  flesh.  At  first  it  may  merely  be  that 
that  the  body-weight  fails  to  exhibit  its  usual  weekly  increase. 
It  soon  becomes  apparent,  however,  that  an  actual  decline 
in  weight  is  taking  place,  owing  to  wasting  ol  the  soft  tissues. 
Loss  of  elasticity  of  the  skin  covering  the  deltoids,  glutei,  and 
adductor  muscles  of  the  thighs  is  one  of  the  earliest  and  most 


324  THE    CHRONIC    GASTROENTERITIS    OF    INFANCY. 

conspicuous  signs  of  failure  of  nutrition,  the  superficial  tissues 
becoming  flabby  and  capable  of  being  pinched  up  between 
the  fingers  into  loose  folds.  The  subsequent  absorption  of 
the  subcutaneous  fat  causes  a  peculiar  wrinkling  of  the  epi- 
dermis, so  that  after  a  short  time  it  hangs  loosely  about  the 
arms  and  thighs,  and  becomes  arranged  in  a  series  of  fine 
plaits  along  the  inner  margins  of  the  buttocks. 

Loss  of  flesh  from  the  face  tends  to  accentuate  the  lines 
which  normally  exist  round  the  eyes  and  mouth,  while  the  deep 
furrows  produced  by  the  incessant  whining  and  crying  of  the 
infant  give  rise  to  that  peculiar  pinched,  aged,  and  woebegone 
expression  which  is  so  characteristic  of  the  disease.  Next  in 
order  of  frequency,  the  skin  covering  the  abdomen  and  scapulae 
exhibits  the  same  flabby  and  wrinkled  appearance;  indeed,  so 
loose  do  the  integuments  become  in  these  regions,  that  it  often 
appears  possible  to  grasp  a  handful  of  tissue  and  to  suspend 
the  wasted  infant,  like  a  rabbit,  by  the  skin  of  its  back. 
Among  the  voluntary  muscles,  the  adductors  and  extensors 
of  the  thighs,  the  gastrocnemei,  deltoids,  and  scaleni  are  the 
first  to  show  signs  of  atrophy,  and  after  a  time  present  the 
appearance  of  thin  cords  when  put  upon  the  stretch.  Finally, 
every  muscle  in  the  body,  both  voluntary  and  involuntary, 
participates  in  the  general  wasting,  so  that  the  long  bones 
become  denuded  of  flesh,  and  look  like  sticks  covered  with 
loose  flolds  of  skin.  The  bones  themselves  cease  to  increase 
in  size  at  an  early  period  of  the  complaint,  and  as  soon  as  the 
soft  tissues  commence  to  waste,  their  compact  tissue  becomes 
gradually  absorbed,  and  they  consequently  become  fragile 
and  prone  to  fracture.  The  bones  of  the  head  also  suffer  in  a 
similar  manner,  more  especially  the  upper  and  lower  maxillae, 
and  this,  combined  with  the  wasting  of  the  cheeks,  makes 
the  cranium  appear  of  undue  size  when  compared  with  the 
face.  In  those  cases,  however,  where  vomiting  and  diarrhoea 
are  very  severe,  the  rapid  loss  of  fluid  from  the  body  causes 
the  anterior  fontanelle  to  recede,  and  the  bones  of  the  vertex 


SYMPTOMS.  325 

to  overlap  along  their  sutures,  so  that  the  whole  head  appears 
to  diminish  in  size.  Contrary  to  what  is  often  observed 
during  convalescence  from  other  disorders  of  early  life,  children 
who  recover  from  chronic  gastrointestinal  catarrh  usually 
remain  stunted  in  stature  for  a  considerable  time,  and,  though 
strong  and  muscular,  may  continue  unusually  short,  and 
often  backward  in  mental  development,  for  many  years  after 
the  cure  of  the  digestive  disease.  The  actual  loss  of  weight 
which  occurs  week  by  week  varies  according  to  the  age  of  the 
child  and  the  severity  of  the  complaint.  Thus,  in  rapid  and 
severe  cases,  as  much  as  10  to  16  oz.  may  be  lost  in  a  single 
week;  but  in  the  more  usual  and  insidious  form  of  the  com- 
plaint the  average  does  not  exceed  3  to  7  oz.  in  the  same 
period  of  time.  As  the  emaciation  proceeds,  the  child 
begins  to  lose  colour,  and  eventually  becomes  the  subject  of 
severe  anaemia.  In  some  cases  the  skin  assumes  a  grey  or 
clay-coloured  tinge,  while  in  others  the  face  and  hands  acquire 
a  faint  yellow  or  bilious  colour;  but  in  all  severe  cases  the 
anaemia  eventually  becomes  extremely  pronounced  and  pro- 
gressive in  character.  The  importance  of  this  symptom  will 
be  further  discussed  when  the  subject  of  prognosis  is  considered. 
The  secretory  functions  of  the  skin  become  impaired  at  an 
early  stage  of  the  complaint,  and  the  surface  of  the  body 
appears  dry  and  harsh  to  the  touch.  Cutaneous  eruptions 
are  common  at  all  periods  6f  the  disease,  and  strophulus 
existed  in  28  per  cent,  of  the  cases  which  came  under  my 
observation.  As  a  rule,  the  eruption  principally  affects  the 
skin  of  the  abdomen  and  face,  but  in  severe  cases  the  whole 
surface  of  the  body  may  be  closely  studded  with  papules. 
In  some  cases  the  rash  only  makes  its  appearance  in  the 
evening  after  the  body  has  been  washed,  and  is  then  attended 
with  such  intense  irritation  that  the  child  is  prevented  from 
sleeping  during  the  early  part  of  the  night.  Eruptions  of  an 
eczematous  nature  are  extremely  common  in  advanced  or 
neglected  cases,  and  existed  in  38  per  cent,  of  my  cases  of  the 


326  THE    CHRONIC    GASTROENTERITIS    OF    INFANCY. 

disease.  As  a  rule,  the  scalp  and  posterior  portions  of  the 
pinnae  are  the  parts  most  frequently  attacked,  but  in  severe 
instances  the  folds  of  the  groins  and  axillae,  as  well  as  the  face, 
neck,  buttocks,  and  thighs,  may  be  affected  in  a  similar 
manner.  In  very  chronic  cases,  small  boils,  or  subcutaneous 
abscesses  containing  curdy  pus,  are  apt  to  make  their  appear- 
ance upon  the  buttocks  and  backs  of  the  thighs,  and  give  rise 
to  unhealthy-looking  ulcers,  which  penetrate  some  distance 
into  the  subjacent  tissues.  The  constant  contact  of  the  acid 
dejecta  with  the  skin  over  the  gluteal  region  causes  it  to 
become  reddened  and  excoriated;  while  not  infrequently 
superficial  ulcerations  occur  round  the  anus  and  in  its  neigh- 
bourhood. In  rare  instances  sloughing  of  the  prepuce  and 
scrotum  or  gangrene  of  the  vulva  is  observed.  In  the  later 
stages  of  the  complaint  the  hands  and  feet  often  become  puffy 
and  oedematous,  and  even  the  skin  of  the  legs  and  thighs  may 
exhibit  some  degree  of  pitting  upon  pressure.  This  condition 
is  usually  ascribed  to  disease  of  the  kidney,  but  in  most  cases  it 
is  due  to  a  gradual  failure  of  the  circulation. 

Chronic  gastroenteritis  is  usually  accompanied  by  a 
remittent  form  of  pyrexia,  the  internal  temperature  of  the  body 
rising  to  about  100  or  101°  F.  at  night,  and  falling  to  98  or  99° 
F.  in  the  morning.  In  some  cases  short  spells  of  fever  alternate 
every  few  days  with  apyrexial  periods,  and  in  such  it  is  not 
unusual  to  find  after  death  that  miliary  tuberculosis  has 
complicated  the  original  complaint.  Continuous  fever,  exceed- 
ing 102°  F.,  generally  indicates  either  a  subacute  attack  of 
intestinal  catarrh  or  some  pulmonary  or  other  serious  compli- 
cation. With  the  approach  of  death,  the  temperature  of  the 
body  often  rises  rapidly  and  may  attain  106°  F.  either  at  or 
soon  after  the  fatal  event.  At  the  commencement  of  the 
disease  the  appetite  is  well  maintained,  and  the  child  often 
exhibits  an  insatiable  desire  for  food;  but  as  soon  as  the 
complaint  has  reached  the  chronic  stage  the  appetite  invariably 
declines,  so  that  at  the  last  it  is  almost  impossible  to  persuade 


SYMPTOMS.  327 

the  child  to  swallow  more  than  an  occasional  mouthful  of 
nourishment. 

Thirst  is  always  present,  more  especially  in  those  cases 
where  diarrhoea  or  vomiting  constitutes  the  principal  symptom 
of  the  complaint.  At  first  the  tongue  is  somewhat  redder 
than  normal,  and  the  dorsum  presents  a  thick  coating  of 
greyish-brown  fur;  but  after  a  time  the  organ  tends  to  become 
pale  and  flabby,  and  is  either  quite  clean  or  merely  covered 
with  a  thin  white  fur.  In  the  final  stages  of  the  complaint 
the  mucous  membrane  of  the  tongue,  as  well  as  that  of  the 
buccal  cavity  and  fauces,  becomes  the  seat  of  parasitic  inflam- 
mation, and  small  ulcerations  make  their  appearance  along 
the  sides  of  the  tongue  and  at  the  angles  of  the  mouth.  These 
morbid  conditions  of  the  mouth  are  of  considerable  importance, 
since  they  not  only  tend  to  destroy  the  appetite,  but  cause  so 
much  pain  during  the  act  of  sucking  or  swallowing  that  the 
infant  refuses  its  food,  and  in  consequence  suffers  from  rapid 
emaciation. 

The  urine  is  always  diminished  in  quantity,  and  when  the 
diarrhoea  is  profuse  only  a  few  drachms  may  be  passed  in  the 
course  of  the  twenty-four  hours.  The  fluid  is  usually  turbid 
when  freshly  voided,  and  presents  a  copious  sediment  of  uric 
acid  and  amorphous  urates  after  standing  for  a  short  time. 
Micturition  is  sometimes  accompanied  by  severe  pain  in  the 
perinaeum  or  glans,  and  in  such  cases  it  is  not  unusual  to  find 
crusts  of  crystalline  material  adherent  to  the  orifice  of  the 
urethra  or  embedded  under  the  prepuce.  The  total  acidity 
of  the  urine  tends  to  diminish  during  the  course  of  the  dis- 
ease, but  the  daily  quantity  of  urea  ehminated  usually  ex- 
ceeds the  normal  until  the  body  has  ujidergone  a  considerable 
degree  of  emaciation.  Many  writers  state  that  the  disease  is 
frequently  associated  with  albuminuria  and  glycosuria.  In 
order  to  test  the  accuracy  of  this  statement,  I  had  the  urine 
drawn  off  in  a  large  number  of  cases  and  carefully  tested  for 
these  abnormal  ingredients.     In  all,  only  6  per  cent,  of  the 


328  THE    CHRONIC    GASTROENTERITIS    OF   INFANCY. 

cases  exhibited  a  trace  of  albumin,  while  sugar  was  never 
detected.  These  facts,  taken  in  conjunction  with  the  rarity 
with  which  parenchymatous  nephritis  is  encountered  after 
death,  appear  to  me  to  indicate  that  renal  inflammation  is  by 
no  means  so  common  a  complication  of  chronic  gastro- 
enteritis as  is  commonly  believed. 

The  sediment  of  the  urine  usually  consists  of  crystals  of 
uric  acid,  mixed  with  a  variable  quantity  of  amorphous  urates 
of  sodium  and  potassium,  but  occasionally  hedgehog  crystals 
of  ammonium  urate  or  spherical  masses  of  the  sodium  salt 
can  also  be  detected.  Epithelial  casts  are  rarely  encountered, 
but  hyaline  cylinders,  either  simple  or  filled  with  uratic  salts, 
are  by  no  means  infrequent.     Fatty  casts  I  have  never  observed. 

It  is  usually  a  matter  of  some  difficulty  to  count  the  pulse 
and  to  estimate  its  volume  in  young  infants  affected  with 
inflammation  of  the  digestive  tract,  while  the  heart-sounds 
are  frequently  obscured  by  rhonchi  or  by  an  abnormally  harsh 
vesicular  murmur.  As  a  rule,  in  the  early  stages  of  the 
disease,  the  pulse  varies  between  90  and  no  per  minute, 
according  to  the  temperature  of  the  body  and  the  degree  of 
exhaustion;  but  as  the  disease  progresses  the  radial  pulse 
becomes  more  and  more  feeble,  and  at  the  same  time  increased 
in  frequency.  It  is  a  curious  fact,  however,  that  with  the 
approach  of  death  the  action  of  the  heart  becomes  slow,  and 
often  intermittent,  so  that  perhaps  not  more  than  sixty  beats 
can  be  counted  in  the  minute  when  the  organ  is  auscultated. 
The  respiratory  movements  are  increased  in  frequency  during 
the  early  stages  of  the  disease,  even  in  the  absence  of  any 
pulmonary  comphcation;  but  as  soon  as  the  symptoms  of 
exhaustion  become  pronounced,  the  breathing  is  usually  slow 
and  laboured,  and  may  finally  present  the  characters  of  the 
Cheyne-Stokes  respiration. 

The  exhaustion  of  the  nervous  system  which  results  from 
non-assimilation  of  the  food  and  the  loss  of  fluid  from  the 
bowel,  makes  itself  apparent  in  a  profound  alteration  in  the 


COMPLICATIONS   AND    SEQUELS.  329 

general  appearance  and  behaviour  of  the  child.  The  incessant 
screaming  and  whining  which  characterizes  the  initial  stages 
of  the  complaint  becomes  replaced  by  apathy  and  depression, 
so  that  the  child  lies  in  its  cot  in  a  semi-somnolent  state, 
and  merely  expresses  its  sense  of  discomfort  by  momentary 
contortions  of  the  face  or  by  an  occasional  moan.  In  this 
condition  it  may  remain  for  many  days,  or  even  weeks,  capable 
of  swallowing  food  placed  in  its  mouth,  but  otherwise  exhibit- 
ing but  little  sign  of  life.  Gradually  the  face  becomes  more 
and  more  pinched,  the  extremities  cold  and  livid,  the  pupils 
dilated  and  sluggish  in  reaction,  and  finally  death  is  ushered 
in  so  quietly  that  it  is  almost  impossible  to  discern  the  moment 
when  the  spark  of  life  is  actually  extinguished.  In  a  large 
number  of  cases,  however,  the  infant  suffers  from  either  local 
or  general  convulsions  during  the  last  stages  of  the  disease, 
which  are  characterized  by  sudden  rotation  of  the  eyeballs, 
dilatation  of  the  pupils,  and  tonic  or  clonic  spasms  of  the 
muscles  of  the  extremities.  Sometimes  these  seizures  are 
repeated  at  short  intervals  of  time,  the  child  remaining  uncon- 
scious between  the  attacks,  and  finally  succumbing  to  respira- 
tory failure.  In  other  instances  the  fits  only  occur  once  or 
twice,  and  apparently  exert  no  deleterious  influence  upon  the 
course  of  the  disease. 

Occasionally  retraction  of  the  head  with  strabismus  appears 
to  denote  the  presence  of  meningitis,  but  in  such  cases  signs 
of  inflammation  in  the  brain  can  seldom  be  discovered  after 
death. 

Complications  and  Sequelae. — Among  the  numerous 
complications  that  are  apt  to  occur  during  the  course  of  chronic 
gastroenteritis  those  which  affect  the  pulmonary  organs  are 
the  most  frequent  and  important.  Catarrh  of  the  pharynx 
is  extremely  common  in  cases  where  vomiting  accompanies 
the  gastric  disorder,  and  not  infrequently  spreads  to  the 
mucous  membrane  of  the  larynx  and  trachea,  and  gives  rise 
to  the  short,  dry  cough  and  hoarse  cry  so  frequently  observed. 


33©  THE   CHRONIC   GASTROENTERITIS   OF   INFANCY. 

In  more  than  one-half  of  the  entire  number  of  my  cases, 
examination  of  the  chest  revealed  the  signs  of  bronchitis, 
which  in  29  per  cent,  was  of  sufficient  severity  to  demand  special 
treatment.  Broncho-pneumonia  existed  in  13  per  cent,  of  the 
cases,  and  affected  one  lung  (usually  the  left)  in  8  per  cent, 
and  both  lungs  in  5  per  cent.  In  every  instance  where  death 
ensued  from  gradual  asthenia,  the  lungs  showed  signs  of 
hypostatic  congestion  during  the  last  few  days  of  life,  and 
in  3  per  cent,  a  moderate  effusion  into  the  right  pleural  cavity 
was  recorded.  Acute  pleurisy,  on  the  other  hand,  was 
never  observed,  except  in  association  with  pneumonia.  In 
two  cases,  where  the  patients  succumbed  rapidly  with  the 
symptoms  of  cardiac  failure  associated  with  a  high  temperature, 
purulent  pericarditis  was  found  at  the  necropsy  to  have  been 
the  immediate  cause  of  death;  but  in  neither  instance  was  a 
friction  sound  detected  during  life. 

The  subjects  of  chronic  gastrointestinal  catarrh  are  ex- 
tremely susceptible  to  intercurrent  attacks  of  acute  or  sub- 
acute inflammation  of  the  digestive  tract.  This  complication 
sometimes  ensues  as  a  result  of  some  change  of  diet;  but  during 
the  summer  months  a  large  number  of  chronic  cases  are  always 
attacked  by  the  epidemic  variety  of  intestinal  catarrh.  The 
occasional  occurrence  of  parenchymatous  nephritis  has  already 
been  noticed;  but  in  my  own  practice  I  have  only  seen  one 
case  where  oedema  of  the  face  and  legs  was  associated  with 
the  presence  of  albumin  and  casts  in  the  urine,  and  in  this 
instance  the  infant  eventually  recovered.  Other  writers, 
however,  have  described  a  series  of  symptoms  which  attend  the 
renal  complication,  among  the  most  prominent  of  which  are 
loss  of  elasticity  of  the  skin  over  the  abdomen,  oedema  of  the 
extremities,  vomiting,  restlessness,  and  convulsions,  accom- 
panied by  scanty  and  albuminous  urine  containing  hyaline 
and  epithelial  casts. 

Of  the  cerebral  complications  of  the  disease,  thrombosis  of 
the  venous  sinuses  and  apoplexy  are  the  most  important.     Of 


COMPLICATIONS   AND    SEQUELiE.  33I 

the  former  I  have  only  observed  one  case,  although  it  is  possible 
that  many  others  may  have  escaped  my  notice  or  occurred  after 

the  patient's  last  visit  to  the  hospital. 

The  profound  malnutrition  which  accompanies  chronic 
inflammation  of  the  alimentary  canal  renders  the  subjects  of  the 
complaint  unduly  susceptible  to  the  invasion  of  various  infec- 
iiaiis  diseases,  such  as  measles,  scarlatina,  and  pertussis;  while 
in  hospital  practice,  at  any  rate,  acute  miliary  tuberculosis  is 
responsible  for  a  considerable  proportion  of  the  deaths.  Even 
when  a  child  recovers  from  the  immediate  effects  of  the  disease 
it  is  very  apt  to  suffer  from  rickets  during  the  period  of  con- 
valescence. Thus,  no  fewer  than  27  per  cent,  of  my  cases 
which  eventually  recovered  presented  more  or  less  pronounced 
signs  of  rickets  before  their  final  discharge  from  the  hospital. 

Chronic  purulent  discharges  from  the  nose,  ears,  or  vagina 
are  not  infrequently  encountered  in  these  cases,  and  the  en- 
larged glands  which  make  their  appearance  in  the  neck  or  groin 
occasionally  prove  the  starting-point  of  tuberculous  adenitis. 

There  is,  however,  one  result  of  chronic  enteritis  in 
infancy  to  which  I  would  draw  special  attention,  both  on 
account  of  its  practical  importance  and  also  because  it  ap- 
pears hitherto  to  have  escaped  attention.  It  is  a  well-known 
fact  that  infants  who  recover  from  chronic  inflammation  of 
their  digestive  organs  usually  do  so  in  a  slow  and  unsatisfactory 
manner,  and  not  only  continue  very  susceptible  to  attacks  of 
gastric  catarrh  from  exposure  to  cold  or  from  some  slight 
indiscretion  in  diet,  but  may  remain  for  many  years  stunted 
in  stature  and  deficient  in  strength  and  energy.  But  it  is  not 
so  generally  understood  that  the  gastric  disease  contracted, 
and  apparently  cured,  in  infancy,  is  capable  of  exerting  a 
deleterious  influence  upon  the  functions  of  digestion  in  adult 
life.  Some  years  ago,  when  engaged  upon  a  microscopical 
examination  of  the  stomach  in  persons  dying  of  different  com- 
plaints I  frequently  observed  small  patches  of  cirrhotic  tissue 
in  the  mucous  membrane  near  the  lesser  curvature.     These 


332  THE    CHRONIC    GASTROENTERITIS    OF    INFANCY. 

signs  of  disease  were  obviously  of  old  standing,  and  seldom 
appealed  to  the  naked  eye  by  indications  more  obvious  than 
a  slight  pitting  or  puckering  of  surface.  The  subject  became 
endowed  with  renewed  interest  when  I  afterwards  had  an 
opportunity  of  examining  the  digestive  organs  of  children  who 
had  suffered  during  infancy  from  severe  catarrh  of  the  alimen- 
ta.ry  tract,  and  in  whose  stomachs  well-marked  patches  of 
cirrhosis  could  be  detected  with  the  microscope.  In  these 
cases  also  the  signs  of  disease  were  foimd  chiefly,  though  not 
exclusively,  near  the  lesser  curvature  of  the  organ.  That  this 
particular  region  of  the  stomach  should  so  often  present  the  relics 
of  former  mischief  is  hardly  a  matter  for  wonder  when  it  is 
remembered  that  the  increase  in  the  size  of  the  organ  which 
occurs  after  the  second  year  of  life  mainly  involves  the  cardiac 
and  middle  thirds  of  the  viscus,  and  that  consequently  any 
permanent  damage  done  to  the  mucous  membrane  in  early 
infancy  would  always  be  most  conspicuous  in  the  pyloric  or 
least  altered  portion  of  the  organ. 

There  is  a  distinct  clinical  variety  of  gastric  myasthenia 
which  develops  about  the  time  that  the  growth  of  the  body 
is  completed,  and  proves  most  intractable  to  treatment.  The 
fact  that  this  complaint  finds  its  chief  victims  among  those 
who  exhibit  a  sudden  and  remarkable  rapidity  of  growth 
at  a  somewhat  advanced  age  has  led  to  the  disorder  being 
regarded  as  a  result  of  "outgrowing  of  strength."  But  apart 
from  the  important  distinctions  which  exist  between  the  com- 
plaint in  question  and  that  which  may  reasonably  be  placed  in 
this  popular  category,  it  is  an  interesting  fact  that  in  many  of 
these  cases  evidence  of  the  most  convincing  nature  can  be 
obtained  of  an  attack  of  gastric  or  intestinal  inflammation 
during  the  period  of  infancy.  Thus  in  several  cases  which 
have  come  under  my  immediate  notice,  the  hfe-history  of  the 
patient,  as  obtained  from  the  mother,  was  of  the  following  kind: 
As  an  infant,  the  patient  had  seemed  quite  healthy  until,  owing 
to  a  sudden  failure  of  the  maternal  milk  or  from  some  other 


PHYSICAL   EXAMINATION.  333 

cause  which  prevented  suckling,  recourse  was  had  to  artificial 
methods  of  feeding.  As  the  result  of  this  the  child  immediately 
became  ill,  lost  flesh,  and  suffered  from  sickness  and  diarrhoea, 
and,  in  spite  of  repeated  changes  in  the  diet,  became  so  weak 
and  emaciated  that  the  parents  nearly  abandoned  hope  of  its 
recovery.  Under  medical  care,  however,  it  eventually  im- 
proved, but  remained  for  many  years  unduly  small  for  its  age, 
and  suffered  from  obstinate  constipation  or  from  recurrent 
and  severe '  'bilious  attacks. ' '  After  the  age  of  fifteen  the  growth 
of  the  body  was  extremely  rapid,  and  as  soon  as  it  was  com- 
pleted, symptoms  of  weak  digestion,  accompanied  by  atony 
of  the  colon,  made  their  appearance,  and  had  persisted  ever 
since.  Cases  of  this  nature  constitute  a  distinct  class  of  habit- 
ual dyspeptics,  and  are  encountered  in  every  variety  of  medical 
practice.  Unless  carried  off  by  some  intercurrent  disease  like 
pneumonia  or  tuberculosis,  the  victims  of  this  disorder  remain 
for  the  greater  period  of  their  lives  thin  and  anaemic,  and  not 
infrequently  suffer  from  melancholia  or  h)rpochondriasis.  The 
chain  of  evidence  which  connects  cases  of  this  kind  with 
antecedent  disease  of  the  mucous  membrane  of  the  stomach 
and  intestine  is  at  present  incomplete,  inasmuch  as  it  has 
hitherto  been  impossible  to  submit  their  stomachs  to  a  micro- 
scopical examination;  but  there  can  be  little  doubt  that  chronic 
gastroenteritis  in  infancy  can  leave  its  mark  upon  the  di- 
gestive organs  for  many  years  and  exert  an  important  and 
deleterious  influence  upon  the  functions  of  the  stomach  and 
intestine  in  later  life. 

Physical  Examination. — As  long  as  the  inflammation 
persists  in  a  subacute  form,  the  abdomen  is  found  to  be 
somewhat  retracted,  the  superficial  muscles  rigid,  while 
pressure  with  the  hand  gives  rise  to  pain.  In  the  chronic 
condition,  on  the  other  hand,  the  abdominal  walls  are 
usually  flaccid,  and  the  gaseous  distension  of  the  stomach 
and  bowels  which  commonly  accompanies  the  disease  may 
cause  a  perceptible  separation  of  the  recti  muscles. 


334  THE   CHRONIC   GASTROENTERITIS    OF   INFANCY. 

By  careful  examination,  the  existence  of  dilatation  of  the 
stomach  can  always  be  determined,  and  in  many  instances  the 
lower  border  of  the  organ  is  found  to  extend  below  the  level 
of  the  umbilicus,  When  a  soft  tube  is  passed  into  the  stomach 
and  air  pumped  in  by  means  of  a  hand-bellows,  the  viscus  may 
be  ballooned  with  the  greatest  ease,  a  fact  which  forcibly  demon- 
strates the  presence  of  myasthenia. 

In  those  cases  where  the  disease  is  not  attended  by  vomiting 
and  where  stagnation  of  the  gastric  contents  habitually  occurs, 
the  characteristic  splash  can  generally  be  obtained  by  appro- 
priate manipulation.  Occasionally  the  lower  edge  of  the 
liver  projects  below  the  costal  margin,  while  the  left  lobe  of 
the  organ  is  detected  in  the  left  hypochondrium  in  close 
proximity  to  the  spleen.  When  tenesmus,  arising  from  follic- 
ular ulceration  of  the  large  intestine,  is  a  prominent  symptom 
of  the  case,  the  introduction  of  the  finger  into  the  rectum  gives 
rise  to  pain,  and  often  causes  a  reflex  spasm  of  the  anal  muscles. 

Chemistry  of  Digestion. — The  morbid  processes  which 
occur  in  the  mucous  membrane  of  the  stomach  during  the 
course  of  the  disease  give  rise  to  important  changes  in  the 
chemical  composition  of  the  gastric  juice.  In  appearance, 
the  contents  of  the  organ  vary  considerably,  but  as  a  rule 
they  are  extremely  viscid,  owing  to  an  excess  of  mucus.  For 
this  reason  filtration  is  a  matter  of  much  difficulty,  and  it  is 
often  necessary  to  manipulate  the  material  in  its  crude  state. 
Its  reaction  to  litmus-paper  is  usually  acid,  but  in  advanced 
cases  of  the  disease  the  contents  of  the  stomach  may  be  neutral. 
In  a  certain  number  of  cases  (nine)  I  have  been  enabled  to 
contrast  the  results  of  a  chemical  examination  of  the  contents  of 
the  stomach  made  during  life  with  the  microscopic  appearances 
presented  by  the  organ  after  death,  and  these,  when  taken  in 
conjunction  with  numerous  other  observations  conducted  at 
different  periods  of  the  complaint,  permit  of  several  general 
conclusions  being  arrived  at. 

In   the  first  stage  of    the  disease,   the  contents   of    the 


CHEMISTRY   OF   DIGESTION.  335 

Stomach,  when  extracted  one  and  half  hours  after  the  test- 
meal,  exhibit  a  large  amount  of  mucus  and  much  undigested 
curd.  Leo  states  that  the  total  acidity  in  these  cases  is  often 
higher  than  normal,  owing  to  the  presence  of  organic  acids 
produced  by  fermentation;  but  I  have  never  found  it  to  exceed 
0.135  P^^  c^^^-  HCl,  while  not  infrequently  it  did  not  amount 
to  more  than  0.08  per  cent.  HCl. 

One  of  the  most  important  features  is  the  invariable  absence 
of  free  hydrochloric  acid  and  the  marked  diminution  in  the 
quantity  of  the  mineral  acid  combined  with  the  proteid 
elements  of  the  food.  These  facts  are  in  strict  accordance 
with  our  knowledge  of  the  changes  which  occur  in  the  gastric 
secretion  from  inflammation  of  the  stomach  in  adult  life.  Lactic 
acid,  as  evidenced  by  a  positive  reaction  with  Ueffelmann's 
solution,  is  present  in  every  case,  and  traces  of  butyric  acid 
may  frequently  be  detected.  Under  the  microscope,  pieces  of 
curd,  fat  globules,  epithelial  cells,  and  numerous  bacteria 
are  observed. 

In  the  second  stage  of  the  disease,  where  the  gastric  glands 
are  beginning  to  suffer  compression  by  the  newly  formed 
fibrous  tissue,  the  contents  of  the  stomach  still  contain  an 
excess  of  mucus,  and  often  possess  a  pungent  smell  from  the 
presence  of  butyric  acid.  Free  hydrochloric  acid  is  invariably 
absent,  and  the  combined  acid  is  much  diminished,  although, 
owing  to  the  presence  of  secondary  acids,  the  total  acidity 
may  exceed  40. 

In  the  third  and  atrophic  stage  of  the  complaint,  the  secretion 
of  mucus  usually  fails,  and  the  residue  of  a  test-meal,  even 
after  a  lengthy  residence  in  the  stomach,  may  possess  hardly 
any  appreciable  degree  of  acidity.  Pepsin  may  also  be  absent 
from  the  mixture,  although  both  it  and  the  rennet  ferment 
can  still  be  extracted  from  the  mucous  membrane  by  the 
introduction  of  dilute  hydrochloric  acid  into  the  stomach. 

The  comparative  slowness  with  which  the  stomach  disposes 
of  the  food  it  receives  affords  important  corroborative  evidence 


336  THE    CHRONIC    GASTROENTERITIS    OF   INFANCY. 

of  the  enfeebled  state  of  its  muscular  walls.  Thus,  in  eight 
cases  in  which  the  symptoms  of  the  complaint  were  supposed 
to  have  existed  from  two  to  four  weeks,  the  organ  was  found 
to  contain  curdled  milk  from  two  and  a  half  to  two  and  three- 
quarter  hours  after  the  administration  of  2  oz.  of  milk  and 
water.  In  twenty-three  instances,  where  the  disease  had 
existed  from  six  to  twelve  weeks,  the  stomach  was  seldom 
found  to  be  empty  until  after  the  lapse  of  three  hours  and  a 
quarter;  while  in  nine  cases  which  exhibited  a  duration  of 
more  than  three  months,  the  organ  often  contained  an  ap- 
preciable amount  of  milk  five  hours  after  the  meal. 

Examination  of  the  Blood. — It  appears  to  be  an  estab- 
lished fact  that  at  birth  the  blood  is  exceptionally  rich 
both  in  corpuscles  and  colouring  material.  The  exact  number 
of  the  red  corpuscles,  as  estimated  by  different  observers, 
varies  between  5,360,000  (Hayem)  and  6,700,000  (Otto, 
Gundobin)  per  cubic  millimetre,  while  about  12,000  to  15,000 
white  corpuscles  are  to  be  found  in  the  same  volume  of 
blood.  During  the  first  few  hours  of  life  a  slight  increase 
in  the  number  of  corpuscles  can  usually  be  observed,  but 
after  the  lapse  of  a  day  or  two  a  steady  decline  sets  in  until 
the  corpuscular  richness  approximates  closely  to  that  which 
obtains  in  adult  life.  The  blood  of  a  new-born  infant  is  also 
peculiarly  rich  in  haemoglobin,  but  this  likewise  diminishes 
in  quantity  after  the  first  week. 

Quantitative  estimation  of  the  blood  in  infancy  is  beset 
by  considerable  difl&culties,  and  the  conclusions  arrived  at 
are  often  delusive,  owing  to  the  influence  exerted  upon  the 
constituents  of  the  blood  by  the  state  of  the  general  health. 
Thus,  it  is  found  that  a  rise  in  the  body  temperature  causes  a 
rapid  diminution  in  the  number  of  the  red  corpuscles;  while  an 
attack  of  diarrhoea,  probably  by  concentrating  the  fluid  in  the 
circulation,  is  accompanied  by  an  apparent  increase  in  the 
percentage  of  corpuscles  and  haemoglobin. 

In   thirty-one    cases    of    chronic    gastroenteritis,    regular 


PROGRESS   AND    TERMINATION.  337 

estimations  of  the  blood  were  made  by  means  of  the  haemacy- 
tometer  and  haemoglobinometer  of  Gowers.  The  results  of 
these  investigations  appear  to  show  that  at  the  commencement 
of  the  complaint  a  marked  decrease  in  the  percentage  quantity 
of  haemoglobin  may  usually  be  observed.  Thus,  in  fourteen 
cases  where  the  symptoms  of  the  complaint  were  stated  to 
have  lasted  for  less  than  three  weeks,  the  colouring  material 
varied  between  65  per  cent,  and  78  per  cent.,  while  the  cor- 
puscular richness  varied  between  80  per  cent,  and  90  per  cent. 
In  every  case  the  objective  signs  of  anaemia  were  visible  in  the 
hps,  conjunctivae,  and  skin.  In  one  case  of  chronic  marasmus, 
where  microscopical  examination  eventually  proved  that  the 
stomach  and  intestines  were  in  a  condition  of  moderate 
cirrhosis  (Fig.  7),  an  examination  of  the  blood  made  upon 
the  day  previous  to  death  showed,  corpuscles,  78  per  cent.; 
haemoglobin,  66  per  cent.  In  the  last  stage  of  the  complaint, 
where  the  stomach  is  dilated,  and  the  secretion  of  gastric  juice 
reduced  to  a  minimum,  a  steady  diminution  occurs,  both  in  the 
number  of  the  corpuscles  and  in  the  amount  of  haemoglobin, 
so  that  in  very  chronic  cases  it  is  not  unusual  to  find  that  the 
percentage  of  the  former  is  less  than  50,  and  of  the  latter  less 
than  36.  In  such  cases  the  anaemia  is  very  conspicuous,  and 
in  many  instances  the  loss  of  colour  is  so  profound  as  to 
simulate  the  pernicious  form  of  the  disease  in  adult  life.  It  is 
therefore  not  unreasonable  to  infer  that  a  gradual  destruction 
of  the  digestive  and  absorptive  powers  of  the  alimentary  tract 
may  constitute  one  of  the  causes  of  the  severe  anaemia. 

Progress  and  Termination. — The  course  pursued  by  the 
disease  varies  considerably  in  different  cases.  In  out-patient 
practice  it  is  usually  observed  that,  when  the  complaint  has 
once  attained  a  certain  degree  of  chronicity,  it  continues  to 
make  steady  progress  toward  a  fatal  issue,  owing  to  the 
adverse  hygienic  surroundings  of  the  children  of  the  poor  and 
the  impossibility  of  providing  the  patients  with  those  special 
forms  of  nourishment  that  are  indispensable  for  the  main- 


T,^8  THE    CHRONIC    GASTROENTERITIS    OF   INFANCY. 

tenance  of  health.  When  it  is  also  remembered  that  in  such 
cases  medical  advice  is  seldom  sought  until  the  disease  has 
existed  for  many  weeks,  it  is  hardly  surprising  that  chronic 
inflammation  of  the  digestive  tract  in  infancy  is  attended  by 
such  a  long  death-roll. 

In  the  subacute  form  of  the  disease,  where  vomiting  and 
diarrhoea  are  severe,  death  often  occurs  from  asthenia  or  some 
intercurrent  complaint  between  the  fourth  and  the  seventh 
weeks  or  even  earlier.  But  in  the  more  chronic  variety, 
where  progressive  emaciation  and  anaemia  are  the  chief  object- 
ive phenomena,  the  infant  may  linger  for  many  months,  and 
eventually  succumb  either  to  gradual  exhaustion  or  to  one  of 
the  numerous  complications  of  the  disease.  Among  the 
TOO  cases  which  were  selected  for  special  examination,  no 
fewer  than  thirty-three  died  during  the  time  that  they  were 
under  treatment  at  the  hospital.  Even  this  high  percentage 
probably  underrates  the  actual  mortality,  since  it  was  impos- 
sible to  follow  the  ultimate  progress  of  many  of  the  remaining 
cases;  and  I  have  a  strong  impression  that  if  the  truth  could  be 
ascertained,  the  death-rate  from  the  primary  disease  or  its 
sequelae  would  be  nearer  50  than  30  per  cent. 

Among  the  thirty-three  cases  which  were  known  to  have 
ended  fatally,  nine,  or  27.2  per  cent.,  died  from  asthenia,  syn- 
cope, convulsions,  or  from  some  other  cause  directly  connected 
with  the  primary  complaint.  In  six  cases  (18. i  per  cent.) 
death  resulted  from  an  attack  of  acute  intestinal  catarrh; 
in  five  instances  (15  per  cent.)  broncho-pneumonia  was  respon- 
sible for  the  fatal  issue;  while  in  the  remaining  thirteen  (39.7 
per  cent.)  the  infant  contracted  some  infectious  disorder, 
such  as  pertussis,  measles,  or  scarlatina,  which  rapidly  brought 
life  to  an  end. 

With  regard  to  the  actual  duration  of  the  disease  in  the 
fatal  cases,  statistics  have  only  a  limited  value,  owing  to  the 
habitual  inaccuracy  which  characterizes  all  the  statements 
made  by  hospital  patients  concerning  the  ailments  of  them- 


PROGNOSIS.  339 

selves  and  their  children.  As  far  as  could  be  ascertained, 
however,  in  6i  per  cent,  of  the  cases  the  disease  had  lasted 
from  one  to  two  months;  in  27  per  cent.,  from  two  to  four 
months;  in  9  per  cent,  from  four  to  six  months;  and  in  3  per 
cent,  for  more  than  six  months. 

Prognosis. — In  the  early  stages  of  the  complaint,  before  the 
mucous  membrane  of  the  alimentary  canal  has  sufifered  per- 
manent injury,  a  cure  can  usually  be  effected  by  the  strict 
observance  of  those  elementary  principles  which  should 
regulate  the  diet  and  hygiene  of  infancy.  When,  however, 
the  stomach  and  intestines  have  become  the  seat  of  ex- 
tensive cirrhosis,  both  digestion  and  absorption  are  dan- 
gerously impaired,  and  death  will  assuredly  result,  either 
from  general  malnutrition  or  from  an  attack  of  some  inter- 
current disease.  The  main  point  to  determine,  therefore,  is 
whether  the  inflammatory  mischief  has  produced  irreparable 
damage  to  the  digestive  organs  or  not.  Personally,  I  am  in 
the  habit  of  dividing  cases  of  chronic  gastroenteritis  into 
three  classes,  according  to  the  length  of  time  the  disease  has 
lasted,  the  severity  of  the  general  symptoms,  and  the  func- 
tional state  of  the  stomach  as  determined  by  physical  and 
chemical  examination. 

The  first  class  includes  all  cases  in  which  the  complaint 
has  commenced  in  an  insidious  manner,  and  has  not  lasted 
for  more  than  two  or  three  weeks.  In  such  the  main  symptoms 
consist  of  a  gradual  loss  of  flesh,  abdominal  pain,  flatulence, 
and  loss  of  appetite.  Vomiting  only  occurs  at  intervals  or 
after  a  particularly  copious  meal,  while  the  stools  present  a 
pasty  appearance,  alternating  occasionally  with  others  of  a 
more  liquid  character.  Bronchial  catarrh,  if  it  exists  at  all, 
only  affects  the  larger  tubes,  and  the  blood  contains  more 
than  80  per  cent,  of  red  corpuscles,  and  75  per  cent,  of  haemo- 
globin. Examination  of  the  stomach  after  a  test  meal  shows 
that  its  motor  activity  is  so  far  preserved  that  the  organ  is 
empty  within  two  and  a  half  hours;  while  the  curdled  milk 


340  THE    CHRONIC    GASTROENTERITIS    OF    INFANCY. 

which  can  be  withdrawn  at  the  end  of  an  hour  and  a  half 
presents  signs  of  partial  digestion.  Although  free  hydro- 
chloric acid  is  absent,  the  contents  of  the  organ  are  very  acid, 
and  on  examination  it  can  be  shown  that  the  combined  acid 
in  the  mixture  is  not  appreciably  diminished. 

Cases  which  present  these  general  features  are  extremely 
common  and  constitute  the  bulk  of  those  where  progressive 
loss  of  flesh  is  the  chief  symptom  of  the  disease.  The  prog- 
nosis is  good,  since  the  infant,  if  provided  with  diluted  and 
sterilized  cow's  milk  and  cream,  commences  to  improve  at 
once  and  eventually  makes  a  perfect  recovery. 

In  the  second  class,  the  disease  has  existed  for  many  weeks, 
and  has  given  rise  to  organic  changes  in  the  digestive  organs. 
Vomiting  is  often  observed  and  the  motions  are  frequent, 
watery,  and  extremely  offensive.  Anemia  is  present  to  a 
marked  degree,  and  examination  of  the  blood  shows  that  its 
corpuscular  richness  is  less  than  80  per  cent.,  while  the  per- 
centage of  haemoglobin  varies  between  50  and  70.  The 
stomach  is  invariably  dilated,  and  contains  food  three  hours 
or  more  after  the  administration  of  a  test-meal.  The  gastric 
contents  exhibit  an  excess  of  mucus  which  hinders  filtration; 
free  hydrochloric  acid  is  absent,  and  the  quantity  of  the  com- 
bined acid  is  much  diminished.  The  peptic  and  rennet  fer- 
ments are  still  present,  but  the  mixture  after  acidification  digests 
slowly  and  imperfectly.  Bronchitis  is  usually  present,  and 
not  infrequently  the  mouth  is  affected  with  parasitic  stomatitis, 
while  the  anus  and  thighs  are  excoriated  by  the  alvine  dis- 
charges. The  body  of  the  child  is  much  emaciated,  and  the 
temperature  elevated  a  degree  or  two  each  evening. 

In  these  cases  the  prognosis,  both  immediate  and  remote, 
must  be  extremely  guarded,  for,  in  addition  to  the  danger 
arising  from  the  original  disease,  death  is  prone  to  occur  at  any 
time  from  pulmonary  or  other  complications.  When  recovery 
sets  in,  the  first  sign  of  good  omen  is  usually  a  cessation  of 
the  peevish  crying  and  a  greater  degree  of  restfulness  at  night. 


DIAGNOSIS.  341 

This  is  followed  by  increased  appetite,  diminished  thirst,  and 
a  fall  of  the  temperature.  The  body  also  ceases  to  lose  weight, 
though  it  may  be  several  weeks  before  the  child  can  positively 
be  said  to  be  gaining  weight.  When  this  does  take  place,  the 
face  and  neck  are  usually  the  first  to  exhibit  an  increase  in  the 
amount  of  subcutaneous  fat.  A  rapid  increase  in  the  percent- 
age of  haemoglobin  occasionally  precedes  all  other  signs  of 
returning  health,  while  a  marked  improvement  in  the  motor 
and  secretory  functions  of  the  stomach  may  be  regarded  as 
certain  evidence  of  ultimate  recovery. 

In  the  third  class  must  be  included  those  numerous  cases 
where  the  protracted  nature  of  the  complaint  has  reduced  the 
infant  to  a  state  of  extreme  emaciation  and  anaemia.  Although 
the  appetite  may  be  ravenous,  and  the  symptoms  of  disordered 
digestion  but  httle  apparent,  the  child  continues  to  go  from 
bad  to  worse,  despite  every  care.  Examination  of  the  stomach 
shows  it  to  be  considerably  dilated  and  in  the  habit  of  retain- 
ing food  for  several  hours;  while  its  contents,  when  extracted 
an  hour  and  a  half  after  a  test-meal,  contain  hardly  any  mucus 
and  are  almost  devoid  of  hydrochloric  acid  and  pepsin.  In 
very  chronic  cases,  even  the  secretion  of  rennet  is  suppressed. 
The  skin  and  conjunctivae  appear  bloodless,  and  if  any  blood 
can  be  extracted  by  pricking  the  finger,  it  presents  a  pale  pink 
and  watery  appearance,  and  is  found  to  contain  less  than  50 
per  cent,  of  corpuscles  and  haemoglobin. 

In  such  cases  the  prognosis  is  hopeless,  for  the  atrophic 
condition  of  the  mucous  membrane  of  the  alimentary  tract 
precludes  any  possibility  of  the  digestive  organs  regaining 
that  degree  of  functional  activity  which  is  necessary  for  the 
preservation  of  life. 

Diagnosis. — The  diagnosis  of  chronic  gastroenteritis 
seldom  presents  any  material  difficulty.  It  is  true  that  loss 
of  flesh  and  anaemia  may  accompany  such  diseases  as  con- 
genital syphilis,  rickets,  and  tuberculosis,  but  in  these  cases 
some  other  symptoms  of  the  complaint  are  invariably  pres- 


342  THE    CHRONIC    GASTROENTERITIS    OF   INFANCY. 

ent  and  aid  in  its  detection.  Thus  in  congenital  syphilis, 
there  is  usually  a  history  of  snuffles,  the  nose  is  flattened,  and 
scabs  or  sores  may  be  observed  about  the  nostrils  or  angles 
of  the  mouth.  The  skin  of  the  body  is  dry  and  wrinkled  and 
often  covered  with  a  coppery  eruption.  Mucous  tubercles 
may  sometimes  be  detected  in  the  mouth  or  round  the  anus, 
while  the  buttocks,  hands,  and  feet  may  present  the  red  and 
polished  appearance  so  characteristic  of  the  disease.  In 
the  inflammatory  disease,  on  the  other  hand,  the  skin  has  an 
earthy  tint,  and  if  any  eruption  is  present,  it  is  of  a  strophu- 
lous,  and  not  of  a  specific,  nature.  The  excoriated  condition 
of  the  skin  round  the  anus  is  also  quite  different  from  the 
appearance  presented  by  the  parts  in  cases  of  syphilis. 

In  acute  general  tuberculosis,  the  most  noticeable  symp- 
toms arise  from  the  implication  of  the  pulmonary  organs. 
The  child  coughs  incessantly,  and  examination  of  the  chest 
reveals  either  generalized  bronchitis  or  patchy  consohdation. 
The  fever  which  accompanies  the  disease  is  of  a  remittent 
character,  and  much  more  severe  than  in  cases  of  catarrh  of  the 
alimentary  tract.  The  bowels  are  more  often  confined  than 
loose  in  their  action,  and  copious  perspirations  occur  at  night- 
time. As  the  disease  progresses,  the  legs  and  ankles  become 
oedematous,  and  in  many  cases  the  meninges  or  peritoneum 
are  invaded  by  tubercle. 

When  the  wasting  of  the  body  arises  from  rickets,  the 
changes  in  the  bones  of  the  skull  or  extremities,  delayed 
dentition,  the  tumid  belly,  and  other  signs  of  the  disease  are 
a  sufficient  guide  to  the  nature  of  the  complaint. 

Treatment. — General. — Whenever  the  gastric  or  intestinal 
symptoms  are  severe,  the  child  should  be  confined  to  its  cot, 
and  the  air  of  the  bedroom  maintained  at  a  temperature  of 
about  65°  F.  In  less  urgent  cases,  the  infant  may  be  wheeled 
out  into  the  fresh  air  once  or  twice  a  day,  if  the  weather  permits. 
A  warm  bath  may  be  given  night  and  morning,  care  being 
taken  to  avoid  any  exposure  to  cold.     In  every  case  the  child 


TREATMENT.  343 

should  be  warmly  but  not  too  heavily  clad,  and  it  is  wise  to 
keep  a  flannel  bandage  or  some  carded  wool  covered  with  flan- 
nelette constantly  applied  round  the  abdomen. 

If  the  nates  show  any  signs  of  redness  or  excoriation,  they 
should  be  carefully  cleansed  once  or  twice  a  day  with  thick 
oatmeal  and  water,  and  afterward  dusted  over  with  a  powder 
composed  of  equal  parts  of  oxide  of  zinc  and  starch,  or,  if 
necessar}',  dressed  with  zinc  or  boracic  ointment.  The  nap- 
kins must  be  changed  at  regular  intervals,  and,  along  with  any 
other  soiled  hnen,  should  be  thoroughly  disinfected  before  being 
washed.  If  phimosis  is  present,  an  attempt  must  be  made  to 
dilate  the  orifice  of  the  prepuce  in  order  to  promote  the  complete 
and  regular  evacuation  of  the  contents  of  the  bladder.  Symp- 
toms of  collapse  require  to  be  combated  by  the  application  of 
warmth  to  the  extremities,  and  by  the  administration  of  suitable 
stimulants;  while  thrush  and  the  various  other  complications 
of  the  disease  must  be  treated  in  the  ordinary  manner.  As 
soon  as  convalescence  is  well  advanced,  much  good  will  usually 
accrue  from  a  few  weeks'  residence  in  the  country  or  by  the 
seaside. 

When  the  stomach  is  much  dilated  and  its  contents  ex- 
hibit an  excess  of  mucus,  it  is  wise  to  cleanse  the  organ  before 
active  treatment  is  commenced.  For  this  purpose  a  soft  cathe- 
ter of  moderate  diameter  should  be  employed,  and  warm 
water  introduced  into  it  through  a  glass  funnel  under  atmos- 
pheric pressure.  Occasionally,  however,  some  difficulty  is 
experienced  in  the  evacuation  of  the  contents  of  the  stomach 
by  the  simple  process  of  siphonage,  and  it  is  necessary  to  re- 
place the  funnel  by  a  glass  syringe,  and  to  empty  the  organ  by 
means  of  suction.  For  the  purposes  of  lavage,  pure  water  at 
the  temperature  of  the  body  is  to  be  preferred  to  anything  else, 
the  fluid  being  introduced  slowly  and  in  quantities  not  ex- 
ceeding 2  oz.  at  a  time.  The  addition  of  a  few  grains  of  bi- 
carbonate of  sodium  to  each  douche  is  of  value  in  those  cases 
where  the  vomit  contains  an  excess  of  tenacious  mucus.     Per- 


344  THE    CHRONIC    GASTROENTERITIS    OF    INFANCY. 

sonally,  I  am  opposed  to  the  use  of  such  antiseptics  as  resorcine, 
boracic  acid,  and  naphthahn  for  the  purposes  of  lavage,  since 
absorption  readily  takes  place  from  the  stomach,  and  serious 
symptoms  have  been  known  to  follow  the  use  of  even  the  least 
poisonous  of  these  remedies.  In  the  severe  and  obstinate 
forms  of  the  disease  it  is  necessary  to  cleanse  the  organ  every 
morning,  but  after  a  few  days  three  times  a  week  is  usually 
sufficient. 

The  soft  tube  and  funnel  are  also  of  considerable  use  in 
the  performance  of  forcible  feeding  (gavage).  It  is  well 
known  that  many  infants  who  reject  everything  they  swallow 
will  retain  in  their  stomachs  any  food  which  has  been  forcibly 
injected  into  the  organ.  This  fact  is  made  use  of  in  cases  where 
persistent  vomiting  precludes  the  administration  of  nutriment 
by  the  mouth;  and  it  is  often  found  that  after  forcible  feeding 
has  been  employed  for  a  short  time,  the  tendency  to  emesis 
disappears.  This  method  is  also  of  value  in  the  later  stages 
of  the  complaint,  when  an  absence  of  appetite  prevents  the 
child  from  taking  a  sufficient  supply  of  nourishment. 

Diet. — Since  the  majority  of  cases  of  chronic  gastroen- 
teritis arise  from  improper  feeding,  the  selection  of  a  suita- 
ble dietary  is  a  matter  of  the  greatest  moment.  In  breast- 
fed children  the  state  of  the  mother's  health  must  be  made 
the  subject  of  careful  examination  and  her  milk  submitted  to 
analysis.  Should  she  be  found  to  be  suffering  from  some  grave 
constitutional  or  organic  disease  or  if  the  infant  exhibits  a 
marked  distaste  for  the  breast  and  suffers  from  sickness  or 
purging  after  each  meal,  it  is  advisable  to  prohibit  nursing 
and  to  procure  a  wet-nurse  instead.  If,  however,  the  child 
takes  the  breast  with  avidity,  but  appears  dissatisfied  at  the 
end  of  the  meal,  it  is  probable  that  the  symptoms  of  inanition 
result  from  the  innutritious  quality  of  the  mammary  secretion. 
In  these  cases  the  breast  must  be  supplemented  by  humanized 
milk  or  some  other  modification  of  cow's  milk. 

In    the  case  of  hand-fed  children,   all  varieties  of  milk 


TREATMENT.  345 

and  farinaceous  foods  must  be  suspended  until  the  alimentary 
canal  has  been  cleansed  from  the  masses  of  curd  and  fermenting 
material  with  which  it  has  been  overburdened.  The  sub- 
sequent choice  of  a  dietary  must  depend  upon  the  severity 
of  the  digestive  disease.  When  vomiting  or  diarrhoea  con- 
stitute the  prominent  features  of  the  case,  fresh  milk  almost 
invariably  disagrees,  owing  to  its  tendency  to  undergo  fer- 
mentation in  the  inflamed  stomach.  It  is  necessary,  therefore, 
to  maintain  the  strength  of  the  infant  by  the  judicious  employ- 
ment of  albumin-water  or  the  various  animal  broths.  Veal, 
mutton,  or  chicken  broth  may  be  given  every  hour  in  doses 
of  a  tablespoonful  or  more;  or  raw  meat  juice,  Valentine's 
meat  juice,  oxo,  or  bovril.  After  the  lapse  of  twenty-four 
hours,  whey  may  be  tried,  and  if  this  agrees,  a  little  cream 
may  be  added  to  it.  Should  the  irritability  of  the  stomach 
continue,  a  few  drops  of  brandy  or  champagne  or  white 
wine  whey  may  be  given  with  each  meal.  As  the  child  con- 
tinues to  improve,  the  diet  may  be  further  strengthened  by 
the  addition  of  Mellin's  food,  bread  jelly,  cream  mixture, 
or  even  the  yolk  of  an  egg  beaten  up  with  barley-water  and 
brandy. 

As  soon  as  the  gastric  and  intestinal  symptoms  have  to  a 
great  extent  subsided,  a  cautious  trial  may  be  made  with  milk. 
In  severe  cases  this  should  always  be  peptonized  at  first  and 
given  in  the  proportion  of  one  part  to  three  or  four  of  barley- 
water.  In  ordinary  cases  artificial  peptonization  is  not  neces- 
sary, and  sterilized  milk  suitably  diluted  with  barley  or 
albumin-water  may  be  employed  instead.  Should  the  diarrhoea 
continue  in  abeyance  and  the  stools  fail  to  exhibit  an  excess 
of  undigested  curd,  the  proportion  of  milk  may  be  cautiously 
increased  until  the  child  can  take  equal  parts  of  milk  and 
barley-water  without  discomfort.  In  rare  instances  the  un- 
sweetened form  of  condensed  milk  or  Horlick's  malted  milk 
is  foimd  to  agree  when  every  other  form  produces  sickness 
or  diarrhcea;  but  the  former  should  not  be  given  in  a  proportion 


346  THE    CHRONIC    GASTROENTERITIS    OF   INFANCY. 

greater  than  one  teaspoonful  to  eight  ounces  of  water  until  its 
effects  have  been  adequately  tested. 

After  the  age  of  six  months  it  is  advisable  to  add  a  certain 
quantity  of  farinaceous  material  to  the  dietary.  For  this 
purpose  malted  foods  are  particularly  valuable  and  a  tea- 
spoonful  of  Mellin's  food  may  be  mixed  with  the  milk  or 
broth.  At  a  later  period  a  little  whole-meal  flour,  oatmeal, 
arrowroot,  or  the  Revalenta  Arabica  prepared  with  powdered 
malt  may  be  used.     Sanatogen  is  sometimes  useful. 

In  every  case  the  food  must  be  given  at  regular  intervals, 
and  the  utmust  care  taken  to  ensure  the  cleanliness  of  the 
various  cooking  utensils  employed  in  its  preparation.  Under 
ordinary  conditions,  it  should  be  warmed  to  the  tempera- 
ture of  the  body  previous  to  its  administration,  but  when 
diarrhoea  is  severe  it  should  be  artificially  cooled  by  means 
of  ice,  so  as  to  avoid  exciting  the  peristaltic  movements  of 
the  intestine.  In  the  chronic  forms  of  the  disease,  especially 
when  the  children  have  been  nourished  entirely  upon  preserved 
milk  and  farinaceous  foods,  it  is  by  no  means  uncommon 
to  observe  a  tendency  to  swelling  and  ulceration  of  the  gums. 
This  condition  is  always  accompanied  by  severe  anaemia,  and 
seems  to  be  of  scorbutic  origin.  In  such  cases  the  administra- 
tion of  a  small  quantity  of  orange-  or  lemon- juice  every  day  is 
followed  by  a  rapid  improvement  both  in  the  general  health 
and  also  in  the  state  of  the  digestive  organs.  After  the  age 
of  twelve  months  a  little  fresh  vegetable  should  be  included 
in  the  dietary,  well-boiled  onion,  celery,  asparagus,  potato,  or 
vegetable  marrow  being  the  most  suitable.  Henoch  speaks  of 
the  value  of  a  compote  made  from  dried  whortleberries  in  cases 
of  obstinate  diarrhoea;  while  in  certain  country  districts  acorn- 
tea  is  extensively  used  for  a  similar  purpose. 

But,  despite  every  effort,  there  will  always  be  found  a 
certain  number  of  cases  which  are  unable  to  take  liquid 
nourishment  without  suffering  from  diarrhoea.  In  such  the 
use  of  the  raw  meat  pulp  is  often  attended  by  very  satisfactory 


TREATMENT.  347 

results.  The  pulp  must  be  prepared  in  a  careful  manner 
and  given  at  first  in  teaspoonful  doses  at  intervals  of  two  or 
three  hours.  As  a  rule,  children  soon  acquire  a  liking  for 
the  raw  meat,  but  should  any  serious  aversion  be  shown  the 
pulp  may  be  mixed  with  a  little  sweet  gravy  or  made  into 
a  jelly.  As  soon  as  tolerance  has  been  established,  the  dose 
of  the  pulp  may  be  cautiously  increased,  until  the  child  can 
take  half  a  pound  of  meat  in  the  course  of  the  twenty-^four 
hours.  At  first  the  stools  are  apt  to  be  somewhat  increased 
in  number  and  are  accompanied  by  a  horrible  odour  of 
decomposition;  but  in  the  course  of  time,  and  especially  if 
pepsin  along  with  an  antiseptic  is  administered  after  each 
meal,  the  motions  assume  a  more  natural  appearance.  The 
only  danger  attendant  upon  the  use  of  uncooked  meat  lies  in 
the  possible  introduction  of  some  intestinal  parasite;  but 
careful  selection  and  examination  of  the  meat  is  usually  suf- 
ficient to  prevent  this  accident.  It  is  a  great  mistake  to  dis- 
card the  meat  pulp  as  soon  as  the  infant  shows  signs  of  improve- 
ment, for  it  too  often  happens  that  the  premature  use  of  milk 
or  starchy  foods  is  followed  at  once  by  a  serious  relapse. 

The  use  of  a  diffusible  stimulant  is  indicated  in  all  cases 
which  exhibit  a  tendency  to  exhaustion  or  heart  failure.  As 
a  rule,  the  white  wine  whey,  when  given  in  dessertspoonful 
doses,  meets  all  requirements,  but  under  exceptional  conditions 
recourse  must  be  had  to  good  pale  brandy,  whisky,  burgundy, 
or  champagne.  The  brandy  can  be  advantageously  combined 
with  egg,  as  in  the  brandy  mixture  of  the  Pharmacopceia. 

Both  koumiss  and  kefir  are  spoken  favourably  of  by  cer- 
tain writers,  but  as  a  rule  their  effects  are  disappointing. 

Of  late  years  sour  milk  prepared  after  the  manner  recom- 
mended by  Metchnikoff  has  been  extensively  used  in  the  treat- 
ment of  chronic  diarrhoea  in  children.  As  a  rule,  half  a  pint 
given  in  divided  doses  each  day  and  continued  for  several  weeks 
exerts  a  most  beneficial  influence  upon  the  disease,  especially 
if  the  stools  are  green  and  malodorous.     This  preparation  is, 


348  THE    CHRONIC    GASTROENTERITIS    OF   INFANCY. 

however,  apt  to  produce  vomiting  and  should  be  given  with 
caution  when  emesis  is  a  prominent  symptom  of  the  case. 
In  other  instances  20  grains  or  more  of  the  powdered  lac- 
tobaciUine  mixed  with  diluted  cow's  milk  and  sugar  answers 
very  well,  but  I  have  never  seen  any  decided  improvement 
follow  the  use  of  the  lactic  acid  ferment  made  in  tablet  form. 
Medicinal. — The  principles  which  should  regulate  the 
medicinal  treatment  of  the  disease  are  essentially  the  same  as 
those  adopted  in  the  acute  form  of  the  complaint.  If  the  diar- 
rhoea is  not  urgent,  and  the  stools  contain  lumps  of  undigested 
food  which  are  passed  with  pain  and  straining,  it  is  advisable 
to  administer  a  purge,  in  order  to  rid  the  bowel  of  its  irritant 
contents.  For  this  purpose  castor  oil,  calomel,  or  rhubarb 
and  soda  may  be  employed,  the  first-named  being  usually 
the  most  satisfactory.  Even  in  cases  where  the  motions  are 
liquid  and  passed  with  a  moderate  degree  of  frequency,  small 
doses  of  the  castor-oil  mixture  with  perchloride  of  mercury, 
or  calomel  (one-eighth  to  a  sixth  of  a  grain),  or  grey  powder 
(quarter  to  half  a  grain),  given  every  three  or  four  hours,  are 
attended  by  beneficial  results.  After  these  measures  have 
been  persevered  with  for  a  day  or  two,  active  antiseptic  treat- 
ment should  be  commenced.  The  generally  accepted  treat- 
ment of  chronic  diarrhoea  consists  in  the  administration  of 
various  astringent  drugs  which  are  supposed  to  exert  a  local 
influence  upon  the  mucous  membrane  of  the  bowel,  and  to 
prevent  the  escape  of  fluid  from  its  vessels.  Accordingly, 
text-books  are  usually  full  of  prescriptions  containing  such 
substances  as  sulphuric  and  nitric  acids,  haematoxylin,  chalk, 
rhatany,  catechu,  tannic  or  gallic  acid,  alum,  sulphate  of 
copper,  acetate  of  lead,  etc.  Some  of  these  drugs  possess  an 
undoubted  value  when  applied  directly  to  the  mucous  mem- 
brane in  the  form  of  rectal  injections;  but  their  routine  ad- 
ministration in  relatively  minute  doses  by  the  mouth  is  both 
unscientific  in  theory  and  valueless  in  practice.  The  inutility 
of  the  ordinary  "diarrhoea  mixtures"  in  the  chronic  complaint 


TREATMENT.  349 

of  infancy  must  be  patent  to  anyone  who  is  in  the  habit  of 
dealing  with  such  cases;  and  from  my  own  experience  I  can 
affirm  that  I  have  never  seen  a  case  cured  by  astringents  in 
which  a  careful  trial  of  antiseptics  and  sedatives  had  previously 
failed.  On  the  other  hand,  it  is  a  common  experience  to 
meet  with  cases  where  the  substitution  of  rational  methods 
of  treatment  for  the  empirical  use  of  astringent  drugs  is  fol- 
lowed at  once  by  immediate  improvement.  Certain  combina- 
tions of  tannin  and  albumin  have  recently  come  into  use,  such 
as  Tannalbin  (grs.  8),  Honthin  (grs.  5-8),  Tannigen  (grs.  3), 
Tanocol  (grs.  7),  all  of  which  have  been  highly  spoken  of  by 
various  authorities. 

Of  the  various  antiseptics,  resorcine  is,  without  doubt,  one 
of  the  most  useful,  owing  to  its  ready  solubihty,  cheapness, 
sweet  taste,  and  non-poisonous  character.  It  must,  how- 
ever, be  given  frequently  and  in  full  doses  (3  to  5  grains), 
and  may  be  advantageously  combined  with  carbonate  of  bis- 
muth. As  a  rule,  the  intestinal  flux  begins  to  abate  after  the 
eighth  dose,  and  the  continued  administration  of  the  drug  is 
not  infrequently  followed  by  obstinate  constipation.  In  other 
cases,  carbolic  acid,  creasote,  iodine,  or  perchloride  of  mer- 
cury may  be  tried.  When  vomiting  is  severe,  the  salicylate 
of  bismuth  (3  to  5  grains),  either  alone  or  combined  with 
a  minute  dose  of  colomel,  is  attended  by  remarkably  good 
results;  or  the  salicylate  of  strontium  (i  to  3  grains)  may  prove 
successful  when  everything  else  has  failed.  Benzol-naphthol 
is  of  service  when  the  large  bowel  is  the  chief  seat  of  the 
disease,  but  it  must  be  given  in  full  doses  (5  to  8  grains,  every 
four  hours),  in  order  to  produce  a  good  effect. 

It  seldom  happens  that  the  diarrhoea  arising  from  simple 
catarrh  of  the  intestine  cannot  be  controlled  by  one  or  other 
of  these  drugs.  In  very  chronic  cases,  however,  the  symptom 
more  often  depends  upon  secondary  follicular  ulceration  of 
the  large  bowel  than  upon  simple  catarrh  of  the  smaller  gut, 
and  in  these  cases  sedative  remedies  are  to  be  preferred  to 


350  THE    CHRONIC    GASTROENTERITIS    OF    INFANCY.. 

antiseptics.  In  such,  a  small  dose  of  Dover's  powder  com- 
bined with  carbonate  of  bismuth  and  chalk  answers  extremely 
well,  or  the  tincture  of  opium  may  be  used  along  with  one 
of  the  mineral  acids.  This  latter  prescription  is  particularly 
useful  in  those  cases  where  the  diarrhoea  is  lienteric  in  char- 
acter, or  where  the  stools  are  habitually  green  in  colour. 
Ipecacuanha  is  often  a  valuable  remedy  in  these  cases,  and 
may  be  given  either  in  the  form  of  the  powder  or  the  wine; 
but  it  must  always  be  combined  with  some  aromatic  or  stim- 
ulant preparation  in  order  to  counteract  its  depressant  effects. 
In  some  instances  it  is  most  efficacious  when  minim  doses  of 
the  wine  are  given  every  hour;  while  in  others  minute  doses  of 
the  powder  (one-sixteenth  to  one-eighth  of  a  grain)  combined 
with  Dover's  powder  and  chalk  or  bismuth,  appear  to  answer 
best.  When  severe  vomiting  follows  each  effort  at  defsecation, 
antimonial  wine  in  minim  doses  every  hour  is  often  attended 
by  success  or  3  minims  of  Vanadine  may  be  given  after  meals. 
In  the  most  severe  cases,  where  tenesmus  is  associated  with 
the  passage  of  blood  and  slime,  and  with  prolapse  of  the 
rectum,  an  enema  of  opium  and  starch  containing  a  small 
dose  of  ipecacuanha  given  twice  a  day  is  of  great  value;  while 
in  obstinate  cases  daily  irrigation  of  the  large  bowel  may  be 
undertaken. 

For  the  due  performance  of  this  operation,  the  patient 
should  lie  upon  his  right  side,  with  the  buttocks  raised,  and 
the  fluid  should  be  allowed  to  flow  into  the  bowel  at  the 
atmospheric  pressure.  Simple  warm  water  (temp.  65°  F.) 
or  a  dilute  solution  of  common  salt  (^  per  cent.)  acts  as 
a  sedative  to  the  inflamed  mucous  membrane,  and  aids  in  the 
removal  of  the  acid  mucus  or  other  irritant  material  which 
may  be  present.  Sometimes  weak  solutions  of  acetate  of 
lead  ^  per  cent.),  nitrate  of  silver  (i  grain  per  ounce), 
alum  (i  grain  per  ounce),  or  salicylate  of  sodium  (5  grains 
per  ounce)  may  be  employed  with  advantage. 

As  soon  as  the  immediate  symptoms  of  the  complaint 


THE    DYSPEPSIA    OF    OLD   AGE.  351 

have  completely  subsided,  the  exhibition  of  tonic  remedies 
is  indicated.  The  bland  preparations  of  iron  are  particularly- 
useful,  though  occasionally  the  perchloride  is  also  beneficial. 
Nux  vomica  and  arsenic  are  valuable  drugs  at  this  stage 
of  the  complaint,  and  may  be  advantageously  combined 
with  a  bitter  infusion.  In  cases  where  the  digestion  con- 
tinues feeble  during  the  period  of  convalescence,  the  glycerin 
of  pepsin,  Holadin,  or  maltine  may  be  administered  im- 
mediately after  the  meals.  Cod-liver  oil  should  not  be  given 
as  long  as  any  tendency  to  diarrhoea  exists. 

(2)  THE  DYSPEPSIA  OF  OLD  AGE. 

After  sixty-five  years  of  age  functional  disorders  of  digestion 
become  extremely  common,  and  even  when  no  abnormal 
symptoms  exist  old  people  usually  suffer  from  an  enfeebled 
or  capricious  appetite  and  find  that  they  can  only  avoid 
indigestion  by  the  observance  of  a  limited  dietary.  As  the 
result  of  a  laborious  statistical  enquiry  into  the  relative  fre- 
quency of  various  forms  of  dyspepsia  at  different  periods  of 
life,  Samuel  Fenwick  found  that  21  per  cent,  of  all  persons  over 
sixty-five  years  of  age  suffered  more  or  less  from  chronic 
indigestion.  My  own  investigations,  while  generally  con- 
firming this  estimate,  have  been  more  directly  concerned  with 
the  causation  of  the  digestive  complaints  met  with  in  advanced 
life,  and  seem  to  indicate  that  out  of  every  100  cases  of  chronic 
dyspepsia  in  persons  over  sixty-five  years  of  age  sixty-six 
are  secondary  to  organic  disease  of  some  important  organ 
of  the  body,  while  the  remaining  thirty-four  owe  their  symp- 
toms to  a  progressive  degeneration  of  the  secretory  structures 
of  the  stomach  and  intestines.  In  the  former  class  the  dis- 
order of  digestion  usually  takes  the  form  of  a  chronic  gas- 
tritis due  to  disease  of  the  kidneys,  prostrate  gland,  heart, 
lungs,  liver,  pancreas,  chronic  gout,  or  inefficient  mastication, 
while  in  about  seven  of  the  sixty-six  cases,  or  in  10.6  per  cent, 
of  the  entire  number,  long-continued  hypersecretion  due  to 


352  THE   DYSPEPSIA    OF    OLD   AGE. 

chronic  ulcer  in  the  vicinity  of  the  pylorus,  gall-stones,  or 
diseased  appendix  is  the  cause  of  the  chronic  indigestion. 
The  true  dyspepsia  of  old  age,  which  depends  upon  a  series 
of  retrograde  changes  in  the  alimentary  tract,  has  hitherto 
received  little  or  no  attention,  and  I  am  consequently  obliged 
to  rely  upon  my  own  observations  for  the  following  notes 
upon  the  subject. 

Pathology. — Some  years  ago,  while  pursuing  with  von 
Recklinghausen  a  histological  investigation  of  stomachs  taken 
from  persons  who  had  died  from  different  complaints,  I  was 
much  struck  by  certain  morbid  appearances  presented  by  the 
organ  in  the  case  of  old  persons  who  had  died  either  from 
an  accident  or  some  acute  disease  and  in  whom  the  other 
viscera  of  the  body  were  quite  healthy.  Further  investiga- 
tions have  fully  confirmed  these  earlier  impressions,  and  it  is 
now  quite  certain  that  with  advancing  age  a  progressive  degen- 
eration affects  the  secretory  structures  of  the  entire  digestive 
canal.  Although  after  the  age  of  fifty  these  changes  are  fairly 
constant,  careful  examination  will  often  detect  their  existence 
at  a  much  earlier  period,  and  in  one  instance  they  were  ex- 
tremely well  marked  in  a  man  in  his  forty-first  year.  To  the 
naked  eye  the  pyloric  third  of  the  stomach  presents  an  attenu- 
ated appearance,  the  rugae  being  practically  absent  and  the 
mucous  membrane  abnormally  smooth,  pigmented  in  patches, 
and  firmly  adherent  to  the  subjacent  muscular  coat.  The 
pyloric  orifice  is  also  less  patent  than  usual  and  readily  tears 
when  stretched.  In  more  advanced  cases  glistening  lines  or 
streaks  may  be  observed  running  parallel  to  the  lesser  curva- 
ture, or  irregular  patches  of  thin,  scar-like  tissue  are  scattered 
over  the  mucous  membrane  near  the  pylorus.  In  such  it  is 
usual  to  find  that  the  walls  of  the  stomach  are  so  thin  and 
white  as  to  resemble  tissue-paper,  while  from  the  size  of  the 
organ  it  is  obvious  that  a  considerable  degree  of  gastrectasis 
must  have  existed  during  life.  Postmortem  digestion  is 
rarely  encountered.     As  a  rule,  the  small  intestine  exhibits 


PATHOLOGY.  353 

the  same  pallid,  thin,  and  inelastic  appearance,  while  the  colon 
is  distended  with  gas  and  unusually  translucent.  Extensive 
atheroma  of  the  abdominal  aorta,  coronary,  and  mesenteric 
arteries  may  usually  be  observed. 

On  microscopical  examination  of  the  pyloric  region  the 
first  sign  of  disease  is  found  to  consist  of  an  overgrowth  of 
the  connective  tissue  that  surrounds  and  supports  the  tubular 
glands,  with  the  result  that  the  latter  appear  attenuated  and 
unduly  separated  from  one  another.  Even  at  an  early  stage 
of  the  disease  the  columnar  epithehum  which  covers  the  surface 
of  the  mucosa  and  lines  the  mouths  of  the  ducts  has  disappeared 
and  the  cells  of  the  glands  have  lost  their  individual  outlines 
and  present  a  granular  appearance.  As  the  disease  progresses 
the  ever-increasing  interstitial  tissue  twists,  distorts,  and 
finally  compresses  the  glandular  structures  until  their  extreme 
fundi  are  merely  represented  by  a  series  of  minute  cysts  lined 
by  a  cubical  endothelium.  Finally  these  disappear  and  the 
mucous  membrane  is  converted  into  a  thin  layer  of  fibrous 
tissue.  Coincidently  with  these  changes  in  the  mucosa  the 
submucous  coat  suffers  from  a  similar  but  less  intense  form  of 
cirrhosis,  accompanied  by  an  obliterative  arteritis  of  its 
nutrient  vessels,  with  the  result  that  the  intervening  muscu- 
laris  mucosae  becomes  more  or  less  destroyed  by  compression. 
At  first  the  muscular  tunic  shows  signs  of  hypertrophy,  but 
sooner  or  later  it  also  becomes  involved  by  an  interstitial  fibrosis 
and  its  contractile  fibres  either  atrophy  or  are  affected  by 
fatty  degeneration.  Unlike  the  similar  condition  which 
results  from  ordinary  interstitial  gastritis,  indications  of  hyper- 
emia are  absent  and  the  peritoneal  coat  is  never  thickened. 
The  cirrhotic  changes  rarely  extend  beyond  the  central  zone 
of  the  stomach;  indeed,  the  connective  tissue  of  the  fundus 
is  usually  very  thin  and  fragile  in  appearance,  while  the  glands 
are  either  dilated  and  devoid  of  cells  or  are  incompletely  filled 
by  globules  of  fat.  In  the  small  intestine  the  villi  are  markedly 
shrunken  and  distorted,  and  the  follicles  of  Lieberkiihn  are 

2,3 


354  THE    DYSPEPSIA    OF    OLD   AGE. 

filled  with  masses  of  degenerated  cells,  while  in  advanced 
cases  the  mucous  membrane  is  more  or  less  completely  de- 
stroyed by  an  interstitial  fibrosis.  Changes  of  a  similar  charac- 
ter are  almost  always  present  in  the  colon,  and  the  head  of  the 
pancreas  is  usually  atrophied  or  fatty. 

If  one  may  argue  from  the  somewhat  similar  changes 
which  affect  the  gastrointestinal  tract  in  cases  of  chronic 
interstitial  nephritis,  pernicious  anaemia,  and  diabetes,  it 
would  seem  probable  that  the  atrophy  of  the  alimentary  organs 
which  occurs  in  old  age  is  an  expression  of  a  mild  but  chronic 
toxaemia,  the  poisons  of  which  produce  irritation  during  their 
elimination  by  the  glands  of  the  gastric  and  intestinal  mucous 
membranes,  and  are  themselves  possibly  produced  by  some 
abnormal  chemical  changes  in  the  contents  of  the  large  bowel. 

With  regard  to  the  chemistry  of  digestion  in  this  condition, 
I  have  usually  found  that  the  total  acidity  of  the  gastric  con- 
tents after  a  test-breakfast  is  less  than  normal  and  varies 
between  30  and  45.  Free  hydrochloric  acid  is  never  met 
with  and  the  proteid  acid  is  also  diminished  in  amount.  Lactic 
acid  is  never  present.  At  an  advanced  stage  of  the  disease 
the  motility  of  the  stomach  becomes  much  impaired,  but 
undigested  food  is  never  found  in  the  viscus  in  the  early 
morning. 

Symptoms. — The  dyspepsia  of  old  age  is  common  to  all 
classes  of  the  community,  but  is  rather  more  frequent  in  women 
than  in  men.  It  usually  develops  between  sixty  and  seventy 
years  of  age  and  gradually  increases  in  severity  with  advancing 
years.  As  a  rule,  the  symptoms  commence  in  an  insidious 
manner,  but  occasionally  their  onset  is  somewhat  abrupt 
and  dates  from  an  accident  or  an  acute  illness.  Flatulence 
invariably  constitutes  the  most  prominent  symptom  of  the 
complaint.  On  rising  from  bed  in  the  morning  a  sense  of 
fulness,  weight,  or  distention  is  usually  experienced  in  the 
upper  part  of  the  abdomen,  accompanied,  perhaps,  by  nausea, 
giddiness,  or  palpitation,  and  not  infrequently  followed  by  an 


SYMPTOMS.  355 

attack  of  retching  which  serves  to  expel  a  quantity  of  odourless 
gas  from  the  stomach.  As  time  goes  on  it  is  noticed  that  the 
appetite  for  breakfast  steadily  diminishes  and  articles  of  food 
which  were  previously  enjoyed  are  renounced  one  after  another 
until  a  piece  of  toast  or  a  few  thin  slices  of  bread  and  butter 
constitute  the  entire  meal.  At  midday  the  desire  for  food  is 
more  pronounced  and  a  fairly  substantial  meal  may  be  taken 
with  relish,  but  during  the  afternoon  epigastric  discomfort, 
eructations  of  gas,  and  a  marked  disinclination  for  mental  work 
frequently  manifest  themselves.  With  the  progress  of  time 
the  sense  of  general  discomfort  becomes  gradually  augmented 
and  it  is  found  that  abdominal  distention  and  gaseous  eructa- 
tions are  almost  constantly  present,  although  the  individual 
himself  is  often  oblivious  of  the  constant  noisy  belchings  or 
borborygmi  which  annoy  his  acquaintances  and  distress  his 
relatives.  Occasionally  pyrosis,  preceded  by  a  cramping 
pain  in  the  epigastrium,  is  a  troublesome  symptom,  but  regur- 
gitations of  an  acid  fluid  into  the  throat  are  rarely  the  subject 
of  complaint.  Nausea  and  retching  after  food  are  by  no 
means  infrequent,  but  vomiting  is  seldom  observed.  Palpita- 
tion of  the  heart,  flushing  of  the  face,  tightness  of  the  chest,  and 
a  difficulty  of  inspiration  are  common  in  stout  persons  and 
greatly  add  to  the  general  distress.  The  flatulence  is  often 
particularly  severe  at  night  and  for  some  hours  the  patient 
may  be  obliged  to  sit  up  in  bed  and  to  make  frequent  and 
varied  efforts  to  expel  the  gas  from  his  stomach.  These 
nocturnal  attacks  are  particularly  common  in  persons  who 
partake  of  a  light  meal  of  liquid  or  semi-solid  material  before 
going  to  bed.  The  bowels  are  always  sluggish  in  their  action 
and  the  stools  are  hard,  deficient  in  colour,  and  evacuated 
with  difficulty.  Anal  prolapse  develops  in  many  instances, 
but  piles  are  rarely  met  with. 

These  symptoms  may  exist  in  varying  degrees  of  severity 
for  many  years,  during  which  the  individual  maintains  his 
physical  strength  in  a  surprising  manner  and  suffers  but  slight 


356  THE    DYSPEPSIA    OF    OLD   AGE. 

loss  of  weight.  He  usually  finds,  however,  that  breathlessness 
ensues  upon  exertion  and  that  mental  worry,  anxiety  or 
physical  fatigue  will  at  once  induce  a  severe  attack  of  flatu- 
lence even  in  the  absence  of  food.  Very  gradually  the  indi- 
cations of  intestinal  disturbance  manifest  themselves,  and 
when  these  become  established  the  failure  of  nutrition  at  once 
attracts  attention.  Week  by  week  the  body  diminishes  in 
weight,  the  lips  and  conjunctivae  become  palhd,  the  skin  loses 
its  elasticity,  and  presents  a  dry,  scurfy  appearance,  and  there 
is  a  rapid  deterioration  of  both  the  physical  and  mental  powers. 
The  patient  now  constantly  wakes  about  5  o'clock  in  the 
morning  with  colicky  pains  in  the  left  side  of  the  abdomen, 
and  a  call  to  stool  results  in  the  expulsion  of  much  flatus  and 
perhaps  a  little  opalescent  fluid.  In  some  cases,  and  more 
especially  in  men,  the  pressure  of  the  distended  intestines 
upon  the  bladder  induces  a  frequent  desire  to  micturate, 
while  the  passage  of  flatus  is  often  attended  by  dribbling  of 
urine.  The  constipation  which  had  previously  been  a  marked 
feature  of  the  case  is  interrupted  by  attacks  of  diarrhoea,  which 
although  not  severe  are  productive  of  great  debility  and  are 
followed  by  further  impairment  of  the  appetite  and  persistent 
dryness  of  the  tongue.  These  symptoms,  while  they  continue 
to  exhibit  a  progressive  character,  are  relieved  to  some  extent 
by  a  residence  in  a  bracing  locality,  careful  dieting,  and  cheer- 
ful companionship,  but  are  exaggerated  by  a  damp  atmosphere 
and  by  indulgence  in  liquid  food.  In  some  instances  cardiac 
failure  or  an  attack  of  diarrhoea  brings  life  to  a  sudden  termina- 
tion, but  as  a  rule  death  ensues  from  general  exhaustion  after  a 
period  of  unconsciousness. 

Treatment.— The  treatment  of  senile  dyspepsia  is  essen- 
tially the  same  as  that  adopted  in  cases  of  achylia  gastrica 
and  atrophy  of  the  stomach.  Mastication  must  be  performed 
in  an  efficient  manner,  and  fresh  teeth  should  be  inserted  when 
necessary.  The  state  of  the  mouth  also  requires  careful 
attention  and  a  wash  of  Condy's  fluid  or  of  carbolic  acid  or 


TREATMENT.  357 

Other  antiseptic  should  be  employed  after  each  meal.  Special 
precautions  must  be  taken  to  protect  the  patient  from  cold, 
and  it  is  always  advisable  that  a  woollen  or  flannel  band  be 
worn  next  the  skin  of  the  abdom.en  both  summer  and  winter. 
Fluids  always  increase  the  tendency  to  flatulence,  and  con- 
sequently beef-tea,  broths,  and  soups  should  be  avoided,  and 
only  a  small  quantity  of  hot  water  be  allowed  at  the  end  of  the 
nleal.  Tea  always  disagrees  and  the  various  sweet  preparations 
of  cocoa  usually  excite  gastric  fermentation,  but  a  palatable 
drink  may  be  made  from  the  cocoa  husks.  Some  individuals 
are  able  to  take  coffee  without  discomfort.  The  addition 
of  a  tablespoonful  of  brandy  or  whisky  to  the  hot  water  taken 
after  meals  often  allays  the  epigastric  discomfort,  but  wines 
and  malt  liquors  must  be  avoided.  Effervescent  drinks  are 
particularly  injurious.  The  fact  that  subacidity  always 
exists  in  these  cases  renders  it  necessary  to  restrict  the  diet 
to  finely  minced  white  fish,  chicken,  game,  brains,  tripe,  sweet- 
breads, calf's  feet,  eggs,  or  scraped  raw  meat.  Green  vege- 
tables and  most  fruits  increase  the  indigestion,  but  cauliflower, 
seakale,  stewed  celery,  asparagus,  and  mealy  potato  may  be 
permitted  in  moderation,  or  a  baked  or  stewed  apple  may  be 
taken  with  the  midday  meal.  Toast  is  preferable  to  bread, 
and  buns,  cake,  and  pastry  must,  as  a  rule,  be  prohibited. 
Raw  milk  should  be  given  with  caution  and  in  many  cases 
it  requires  to  be  diluted  with  lime-water,  mixed  with  a  small 
dose  of  citrate  of  sodium,  sterilized  or  peptonized  before  the 
patient  can  take  it  without  discomfort.  Fats  may  be  allowed 
if  desired,  and  occasionally  cod-liver  oil  is  of  great  benefit. 

The  various  digested  and  semidigested  cereal  foods, 
maltine,  and  sanatogen,  help  to  vary  the  diet,  but  oatmeal, 
barley,  and  rice  should  be  given  with  caution. 

The  main  indications  for  medicinal  treatment  are  to  correct 
the  subacidity  and  to  relieve  the  flatulence  and  constipation. 
For  the  former  it  is  customary  to  prescribe  dilute  hydrochloric 
acid  after  meals,  with  pepsin,  papain,  or  other  artificial  di- 


358  THE   DYSPEPSL4    OF    OLD  AGE. 

gestives,  but  given  in  the  usual  way  the  mineral  acid  rarely 
affords  any  benefit,  while  pepsin  and  its  allies  are  useless. 
A  better  plan  is  to  administer  half  a  tumberful  of  o. i  per 
cent,  solution  of  hydrochloric  acid  half  an  hour  before  meals. 
As  a  rule,  the  greatest  aid  to  gastric  digestion  is  the  introduc- 
tion of  lactic  acid  bacilli  into  the  stomach,  in  the  form  of  milk 
curdled  by  means  of  Metchnikoff's  lactobacilline.  If  this  is 
prepared  properly  and  a  tumblerful  or  more  of  the  curd  be 
taken  twice  each  day  for  a  few  months,  many  of  the  dyspeptic 
phenomena  vanish  and  the  flatulence  is  relieved  or  entirely 
removed.  The  various  tabloids  containing  lactic  bacilli  sold 
in  the  country  are,  according  to  my  experience,  of  very  little 
value.  Maltine  and  takadiastase  are  of  use  in  certain  cases 
of  intestinal  dyspepsia  and  should  be  given  with  the  meals. 
Tonics  always  increase  the  flatulence,  and  even  the  various 
bitters  prescribed  with  a  view  of  increasing  the  appetite  usually 
disagree  after  a  few  days.  In  order  to  relieve  an  attack  of 
flatulence,  a  draught  containing  ether,  ammonia,  and  spirits 
of  cajuput  is  usually  employed,  but  a  far  better  remedy  for 
the  purpose  is  to  be  found  in  the  alcoholic  essence  of  pepper- 
mint introduced  by  Ricqles  and  now  obtainable  at  most  of  the 
large  chemists  in  London.  One  teaspoonful  in  a  sherryglass- 
ful  of  water  seldom  fails  to  relieve  the  excessive  distention  or 
an  attack  of  wind  colic.  For  the  constipation  salines  and 
mineral  waters  should  be  avoided,  and  recourse  be  had  to 
the  mixture  of  maltine  and  cascara,  the  confection  of  senna 
and  sulphur,  an  infusion  of  senna  pods,  or  an  occasional  dose 
of  grey  powder. 


CHAPTER  IX. 

DYSPEPSIA   DEPENDENT  UPON   DISEASES   OF 
OTHER  ORGANS. 

(I)  Lung  Disease;  (2)  Tuberculosis;  (3)  Heart  Disease;  (4) 
Liver  Disease;  (5)  Kidney  and  Urinary  Diseases;  (6) 
Specific  Fevers;  (7)  Syphilis;  (8)  Diabetes;  (9)  Anaemia 
and  Chlorosis;  (10)  Nervous  Diseases;  (11)  Pregnancy; 
(12)  Drugs. 

The  stomach  is  the  great  sympathetic  organ  of  the  body 
whose  fimctions  are  at  once  disturbed  when  any  other  viscus 
is  attacked  by  disease.  In  the  case  of  the  heart  and  hver, 
obstruction  to  the  portal  circulation  is  the  immediate  cause 
of  the  failure  of  gastric  digestion;  in  nervous  affections,  as 
well  as  in  disorders  of  the  blood-making  organs,  a  perversion 
of  the  gastric  secretion  is  usually  encountered,  while  in  specific 
fevers,  Bright's  disease,  syphilis,  phthisis,  and  diabetes  organic 
changes  occur  in  the  mucous  membrane  of  the  digestive 
tract  as  the  result  of  the  special  toxaemias  that  exist  with 
these  complaints.  It  is  obvious,  therefore,  that  no  trustworthy 
opinion  can  ever  be  expressed  as  to  the  cause  of  dyspepsia 
unless  all  the  important  organs  of  the  body  have  been  examined 
and  their  various  functions  investigated  as  carefully  as  those 
of  the  stomach  itself. 

(i)  LUNG  DISEASES. 

Emphysema  gives  rise  to  a  downward  displacement  of 
the  stomach,  and  is  therefore  frequently  accompanied  by 
symptoms  of  gastroptosis  (Chap.  VI).  At  a  later  stage  of  the 
pulmonary  complaint,  as  well  as  in  cases  of  chronic  inter- 
stitial pneumonia  and  pneumonoconiosis,  the  gradual  dilatation 

359 


360  THE    DYSPEPSIA    OF    PHTHISIS. 

of  the  right  side  of  the  heart  induces  congestion  of  the  stomach 
and  a  disorder  of  digestion  similar  to  that  met  with  in  valvular 
disease.  Empyema,  abscess  of  the  lung,  and  bronchiectasis 
are  apt  to  be  accompanied  by  chronic  inflammation  of  the 
stomach  and  intestines  owing  to  the  constant  absorption  of 
toxins  from  the  diseased  tissues.  Of  all  pulmonary  diseases, 
however,  tuberculosis  is  infinitely  the  most  important,  and  the 
varieties  of  dyspepsia  that  are  met  with  in  this  complaint 
are  worthy  of  a  detailed  description. 

THE  DYSPEPSIA  OF  PHTHISIS. 

Two  forms  of  indigestion  are  commonly  observed  during 
the  course  of  chronic  phthisis,  one  of  which,  the  initial  variety, 
coincides  with  the  deposition  of  the  tubercle  and  continues 
until  cavitation  occurs,  while  the  second,  or  terminal  dyspepsia, 
accompanies  the  final  stage  of  the  disease  and  is  due  to  chronic 
gastroenteritis. 

Morbid  States  of  the  Stomach  in  Phthisis. — Dilatation 
of  the  stomach  is  a  very  frequent  accompaniment  of  chronic 
pulmonary  tuberculosis,  and,  indeed,  it  is  rare  to  perform  a 
necropsy  on  a  case  of  this  nature  without  encountering  some 
increase  in  the  dimensions  of  the  organ. 

Louis  estimated  that  two-thirds  of  his  cases  of  phthisis 
exhibited  evidences  of  dilatation  of  the  stomach,  while  among 
100  necropsies  on  cases  of  a  similar  nature  at  which  I  took 
special  notes  on  this  point  the  lower  margin  of  the  viscus 
extended  below  the  level  of  the  navel  in  sixty-four.  In  fifty- 
eight  instances  the  pulmonary  disease  had  existed  for  some  con- 
siderable time  and  the  lungs  presented  numerous  excavations 
with  more  or  less  fibroid  induration.  In  the  remaining  six  cases 
the  tubercular  disease  was  of  more  recent  origin.  It  may  also 
be  noticed  that  in  six  out  of  seven  cases  of  acute  miliary  infec- 
tion no  obvious  increase  in  the  size  of  the  stomach  could  be 
detected. 

It  would  thus  appear  that  the  degree  of  gastrectasis  bears 


MORBID    STATES    OF    THE    STOMACH    IN    PHTHISIS.         361 
I 

a  direct  relation  to  the  extent  and  chronicity  of  the  pulmonary 
lesion — a  fact  which  is  borne  out  by  clinical  observation. 

The  inner  surface  of  the  organ  often  presents  numerous 
irregularities  which  were  first  described  by  Louis  under  the 
term  "etat  mamelonne."  In  this  condition  the  mucous 
membrane  is  closely  beset  with  a  large  number  of  minute 
elevations  arranged  in  the  form  of  patches  or  streaks  in  the 
neighbourhood  of  the  pylorus  Occasionally  the  whole  of  the 
interior  of  the  stomach  is  affected  in  a  similar  manner,  or  in 
rare  cases  the  fundus  alone  presents  any  appearance  of  the 
disease.  Sometimes  these  excrescences  attain  a  considerable 
size  and  form  hemispherical  or  polypoid  tumours  attached  to 
the  surface  by  a  short  stalk. 

This  abnormal  condition  of  the  mucous  membrane  owes  its 
origin  to  the  contraction  of  newly  formed  fibrous  tissue  situated 
between  the  secreting  tubules,  and  is  analogous  to  the  nodular 
appearance  of  the  liver  or  kidney  in  cases  of  chronic  interstitial 
inflammation  of  these  organs. 

Mamillation  of  the  stomach  is  said  to  be  of  frequent  occur- 
rence in  cases  of  phthisis,  but  in  the  postmortem  records  of 
the  Brompton  Hospital  I  can  only  find  that  it  was  observed  in 
about  4  per  cent,  of  the  cases. 

Various  forms  of  ulceration  of  the  stomach  are  encountered 
in  cases  of  chronic  phthisis.  In  some  instances  the  lesion  is  ob- 
viously of  old  standing  and  in  no  way  connected  with  the  lung 
complaint.  In  others  the  disease  appears  to  have  originated 
a  short  time  before  death,  while  occasionally  the  ulceration 
owes  its  origin  to  the  same  cause  as  that  which  produced  the 
pulmonary  mischief. 

The  simplest  variety  of  ulceration  is  the  so-called  hcemor- 
rhagic  erosion.  It  has  already  been  shown  that  minute  effusions 
of  blood  are  apt  to  occur  in  the  mucous  membrane  of  the 
stomach  shortly  before  death  owing  to  congestion  of  the  organ 
from  failure  of  the  right  chambers  of  the  heart.  If,  however, 
life  be  prolonged  for  a  few  hours  and  the  gastric  secretion  is  in 


362  THE    DYSPEPSIA    OF    PHTHISIS. 

an  active  state,  these  punctiform  haemorrhages  may  undergo 
digestion  and  become  converted  into  actual  abrasions.  The 
fully  developed  erosion  presents  the  appearance  of  a  small 
circular  ulcer  surrounded  by  a  slightly  elevated  and  tumid  ring 
of  pale  yellow  colour.  The  base  of  the  ulcer  is  shallow  and  is 
usually  formed  by  the  deeper  layers  of  the  mucous  coat,  but 
sometimes  the  muscular  tunic  is  laid  bare. 

Occasionally  the  inner  surface  of  the  stomach  is  found  to 
be  studded  from  the  cardiac  to  the  pyloric  orifice  with  numerous 
small  circular  ulcers,  several  centimetres  in  diameter  (Paulici, 
Steiner,  Rilliet,  and  Barthez).  This  variety  seldom  extends 
deeper  than  the  muscular  coat  of  the  organ,  but  sometimes 
the  serous  membrane  may  be  exposed.  The  edges  are  sharp 
and  often  undermined,  the  base  smooth  and  somewhat  yellow 
in  colour,  while  the  surrounding  tissue  appears  highly  injected 
with  blood. 

No  tubercles  can  be  discovered,  and  the  microscope  fails 
to  demonstrate  any  specific  cause  for  the  disease. 

This  form  of  gastric  ulcer  is  often  encountered  in  children 
who  have  succumbed  to  general  tuberculosis,  but  I  have  never 
observed  it  in  adults.  It  is  possible  that  it  occurs  some  days 
before  death  as  a  result  of  haemorrhage  into  the  mucous 
membrane. 

In  many  cases  of  pulmonary  tuberculosis  the  mucous 
membrane  of  the  stomach  presents  numerous  sraall  follicular 
ulcers  which  vary  in  size  from  a  few  lines  to  2  cm.  in  diameter. 
The  edges  of  the  excavation  are  slightly  raised  and  either  of  a 
pale  yellow  colour  or  surrounded  by  a  zone  of  highly  injected 
capillaries.  The  disease  seldom  extends  deeper  than  the 
submucous  coat,  but  occasionally  the  mischief  appears  to 
be  progressive  when  the  base  of  the  ulcer  may  involve  the 
muscular  or  even  the  serous  tissue. 

This  variety  of  ulceration  was  noticed  by  Wilson  Fox  in  12 
per  cent,  of  his  acute,  and  18  per  cent,  of  his  cases  of  chronic 
pulmonary  tuberculosis.     It  is  particularly  apt  to  occur  in 


MORBID    STATES    OF    THE    STOMACH   IN    PHTHISIS.         363 

children  who  have  succumbed  to  acute  mihary  tuberculosis, 
and  among  lo  consecutive  cases  of  this  disease  which  I  ex- 
amined at  the  Evelina  Hospital,  well-marked  follicular  ulcer- 
ation was  present  in  four. 

It  is  by  no  means  uncommon  to  find  a  simple  chronic 
ulcer  in  the  stomach  of  a  person  who  has  succumbed  to  pul- 
monary tuberculosis;  and,  indeed,  so  often  do  the  two  diseases 
coexist  that  some  writers  have  attempted  to  estabHsh  a  causal 
relationship  between  them.  But  it  is  probable  that  undue 
stress  has  been  laid  upon  this  point  and  that  the  frequency 
with  which  the  two  affections  are  associated  is  more  apparent 
than  real.  Thus,  Dittrich  only  found  four  open  ulcers  in  403 
necropsies  on  cases  of  phthisis,  and  among  1,000  postmortem 
examinations  performed  at  the  Brompton  Hospital  I  could 
only  find  the  presence  of  a  gastric  ulcer  noted  in  nine  instances. 
Occasionally  several  shallow  ulcers  are  formed  in  the  im- 
mediate vicinity  of  the  pylorus.  This  condition  is  usually 
associated  with  lardaceous  disease  of  the  vessels  in  this  region 
of  the  stomach  and  is  apparently  due  to  the  slow  digestion 
of  the  mucous  surface  in  consequence  of  its  deficient  blood 
supply. 

Ulceration  of  the  stomach  resulting  from  tuberculous  disease 
is  very  seldom  encountered.  Louis  never  met  with  an  ex- 
ample and  Andral  only  mentions  two.  After  a  careful 
search  I  have  been  able  to  discover  the  records  of  twenty-four 
cases  of  this  affection,  several  of  which  are,  however,  open  to 
suspicion;  while  among  the  notes  of  2,000  necropsies  on  cases 
of  phthisis  performed  at  the  Brompton  Hospital  I  could  only 
find  two  instances  in  which  the  disease  was  encountered. 

The  great  rarity  of  tuberculous  disease  of  the  stomach 
appears  to  depend  upon  two  principal  causes.  In  the  first 
place,  unlike  the  intestine,  the  stomach  only  contains  a  small 
amount  of  lymphoid  tissue,  which  is  deeply  situated  in  the 
substance  of  the  mucous  coat.  In  the  second,  the  acid 
secretion  of  the  organ,  though  it  may  not  actually  destroy 


364  THE    DYSPEPSIA    OF    PHTHISIS. 

the  bacilli,  is  distinctly  inimical  to  their  growth,  and  hence, 
even  when  they  are  introduced  in  large  quantities  into  the 
stomach  by  means  of  the  swallowed  expectoration,  they  are 
rendered  temporarily  inert  and  are  passed  on  into  the  small 
bowel  without  having  effected  a  permanent  lodgment. 

Gastroenteritis. — The  first  accurate  description  of  the 
histological  changes  which  are  met  Vv^th  in  the  stomach  in  cases 
of  chronic  phthisis  is  to  be  found  in  the  writings  of  Fox,  Jones, 
Samuel  Fenwick,  and  Habershon,  although  Louis,  Andral, 
Stokes,  and  many  others  at  an  earlier  date  had  published 
excellent  accounts  of  the  macroscopic  appearances  of  the 
disease.  Of  late  years  Marfan,  Schwalbe,  and  several  other 
Continental  pathologists  have  added  to  our  knowledge  of  this 
subject. 

The  various  writers  differ  considerably  among  themselves 
as  to  the  frequency  with  which  the  stomach  is  affected  by 
inflammation  in  cases  of  pulmonary  tuberculosis.  Wilson 
Fox  found  that  the  disease  existed  in  about  62  per  cent,  of 
his  cases  of  phthisis,  while  Lebert  had  previously  noted  its 
presence  in  about  one-fifth  of  his  chronic  and  one-eleventh 
of  his  acute  cases. 

Marfan's  description  of  the  disease  is  based  upon  an  ex- 
amination of  the  stomach  in  twenty-seven  cases  of  phthisis, 
in  eighteen  of  which  (66  per  cent.)  he  was  able  to  detect  signs 
of  inflammation.  Schwalbe  examined  twenty-five  cases,  and 
of  these  fourteen  (56  per  cent.)  presented  appearances  of 
chronic  catarrh,  while  only  six  were  described  as  normal. 

My  own  observations  were  conducted  upon  fifty  cases 
of  pulmonary  tuberculosis  taken  haphazard  from  the  post- 
mortem room,  in  forty-two  of  which  the  microscope  demon- 
strated organic  changes  in  the  mucous  membrane  of  the 
stomach  and  intestines. 

The  chief  results  of  these  observations,  as  regards  the 
stomach,  are  shown  in  the  following  table,  where  it  will  be 
observed  that  an  inflammatory  affection  of  the  gastric  mucosa 


MORBID    STATES    OF    THE    STOMACH    IN    PHTHISIS. 


36: 


is  chiefly  met  with  in  cases  of  phthisis  which  exhibit  cavitation 
of  the  luner. 


Condition  of  lung 
disease 

No.  of 
cases 

Interstitial 
gastritis 

Paren- 
chymatous 
gastritis 

Lardaceous 
disease 

Miliary    tuberculosis . . 
Caseous  tubercle  (with- 
out cavities) 

Tubercle  with  cavities 

10 

13 
27 

2 
23 

2 

I 
6 

8 

Similar  evidences  of  chronic  interstitial  inflammation  may 
be  detected  throughout  the  whole  length  of  the  intestine,  and 
in  advanced  cases  the  villi  of  the  duodenum  present  the  same 
degree  of  cirrhotic  atrophy  as  occurs  in  the  gastroenteritis  of 
infancy  (Fig.  IX). 

Several  writers  have  suggested  that  the  gastroenteritis  of 
phthisis  arises  from  septic  absorption  from  the  lung  (Stokes, 
Pollock,  Marfan,  etc.),  and  this  conclusion  seems  to  be  war- 
ranted by  the  following  facts:  (i)  The  disease  only  occurs 
during  the  last  stage  of  phthisis  after  vomicae  have  been  formed. 
(2)  It  is  usually  associated  with  an  intermittent  form  of  pyrexia 
suggestive  of  septic  origin.  (3)  In  those  cases  where  the 
tuberculous  disease  becomes  arrested  the  gastric  complaint 
also  subsides.  (4)  The  simultaneous  affection  of  several 
organs  (stomach,  intestine,  kidney,  pancreas,  sahvary  glands) 
by  a  similar  pathological  change  indicates  the  existence  of  a 
general  cause.  (5)  The  same  variety  of  inflammation  is  apt 
to  occur  in  cases  of  bronchiectasis  and  caries  of  the  spine  or 
hip  associated  with  long-continued  suppuration. 

Marfan  and  BreviUe  have  been  able  to  isolate  a  chemical 
substance  from  the  pulmonary  cavities  in  cases  of  phthisis 
which  possessed  toxic  properties  when  injected  into  ani- 
mals, though  it  did  not  appear  to  produce  any  noticeable 
change  in  the  mucous  membrane  of  the  gastrointestinal  tract. 


366  THE   INITIAL   DYSPEPSIA. 

Before  I  was  acquainted  with  the  work  of  these  observers,  I  had 
undertaken  an  investigation  of  a  somewhat  similar  nature. 
Large  quantities  of  expectoration  were  obtained  from  cases  of 
phthisis  which  presented  the  physical  signs  of  excavation  along 
with  the  symptoms  of  gastritis,  and  immediately  mixed  with 
an  excess  of  absolute  alcohol.  After  a  lapse  of  several  weeks 
the  material  was  filtered  through  linen,  and  the  semisolid 
residue  extracted  with  distilled  water  and  added  to  the  original 
filtrate,  the  whole  being  afterward  evaporated  to  a  small 
bulk  in  vacuo  at  a  temperature  of  38°  C.  The  syrupy  liquid 
obtained  in  this  manner  was  then  thrown  into  a  large  excess  of 
absolute  alcohol,  and  the  coagulated  proteids  separated  by 
filtration  and  again  extracted  with  distilled  water.  This  pro- 
cess was  repeated  several  times,  and  finally  the  alcoholic  pre- 
cipitate was  collected  and  dried  in  vacuo.  In  this  manner  a 
yellowish-brown  powder  was  obtained,  which  was  easily  soluble 
in  distilled  water,  of  a  neutral  or  slightly  acid  reaction,  and 
possessed  of  the  general  chemical  properties  of  proteose  matter. 
When  this  substance  was  injected  into  animals  in  the  propor- 
tion of  o. I  gram  to  o . 3  gram  per  kilo  of  the  body  weight, 
is  was  usually  followed  by  convulsions,  and  death  often  ensued 
from  respiratory  failure  within  half  an  hour.  The  necropsy 
revealed  intense  congestion  of  the  whole  of  the  gastrointestinal 
tract  with  numerous  haemorrhages  both  there  and  in  the  sub- 
stance of  the  kidney.  No  lardaceous  degeneration  was  ever 
obtained  as  the  result  of  repeated  injections  of  the  toxic 
substance. 

(i)  The  Initial  Dyspepsia. 
(<z)  Frequency. — Hutchinson  was  the  first  to  pubHsh  an 
accurate  statement  concerning  the  frequency  with  which  the 
symptoms  of  indigestion  are  apt  to  accompany  the  develop- 
ment of  pulmonary  tuberculosis;  earlier  writers  having  been 
content  to  express  themselves  in  more  general  terms.  That 
observer  found  that  dyspepsia  was  present  in  92  per  cent,  of 
the  cases  he  investigated,  and  that  in  no  fewer  than  55  per  cent. 


FREQUENCY. 


367 


of  these  the  complaint  had  proved  severe.  These  resuks  were 
subsequently  confirmed  by  Dobell;  while  Samuel  Fen  wick 
estimated  that  St,  per  cent,  of  his  patients  at  the  Victoria  Park 
Hospital  suffered  from  digestive  disorders  during  the  early 
stages  of  their  pulmonary  disease.  Pollock  noted  a  similar 
condition  in  ninety-seven  out  of  113  cases  of  rapid  phthisis,  and 
more  recently  Marfan  has  recorded  that  61  per  cent,  of  his  cases 
of  pulmonary  tuberculosis  suffered  from  symptoms  indicative 
of  indigestion. 

My  own  observations  have  been  chiefly  conducted  at  the 
Brompton  Hospital,  and  are  based  upon  a  personal  exam- 
ination of  500  cases  of  phthisis,  half  of  which  were  males 
and  half  females.  In  each  instance  the  facts  were  elicited 
as  far  as  possible  without  the  employment  of  leading  questions, 
and  the  results  were  recorded  along  with  a  diagram  representing 
the  physical  condition  of  the  lungs  and  the  stomach  at  the 
time  of  the  examination. 

The  various  facts  obtained  in  this  manner  are  exhibited 
in  the  following  table,  and  will  be  more  especially  noticed 
when  the  symptoms  of  the  complaint  are  dealt  with  in  detail. 

MALES. 


Condition  of  lung 

0) 
CO 

OS 
0 

0 

6 

to  .2 

0  a, 

"to    -If 

'a 
0 
> 

'3 
<! 

0) 

y 

C 

Dislikes 

disease 

Fat 

Sugar 

Miliary  tuberculosis. 

Consolidation 

Excavation 

4 

78 

168 

7 
32 

2 

42 

2 
38 
20 

I 

18 
12 

39 
17 

2 

26 
21 

2 

32 
87 

4 
II 

FEMALES. 


Miliary  tuberculosis. 

Consolidation 

Excavation 


5 

2 

2 

I 

2 

3 

96 

65 

81 

74 

49 

51 

63 

58 

149 

121 

93 

36 

32 

28 

32 

94 

9 

12 


368  THE    INITIAL   DYSPEPSIA. 

In  the  meantime  it  is  only  necessary  to  state  that  as  a  general 
result  of  my  investigations,  dyspeptic  phenomena  of  sufficient 
severity  to  attract  the  attention  of  the  patient  are  encountered 
in  about  70  per  cent,  of  all  cases  of  early  phthisis,  but  that  the 
development  of  the  disorder  in  any  individual  case  depends 
to  a  great  extent  upon  the  sex  of  the  patient,  the  type  of  the 
tubercular  disease,  and  the  previous  condition  of  digestive 
organs. 

(b)  Influence  of  Sex. — Dyspepsia  appears  to  be  much  more 
frequent  in  the  female  than  in  the  male.  Thus,  I  found  that 
among  the  ninety-six  cases  of  women  who  were  admitted 
with  signs  of  recent  consohdation,  no  fewer  than  eighty-one 
(84  per  cent.)  complained  of  dyspepsia;  while  among  the 
seventy-eight  men  who  presented  similar  signs  of  disease, 
only  forty-one  (52  per  cent.)  v/ere  affected  with  a  disturbance 
of  digestion.  The  symptoms  of  the  complaint  are  also  apt  to 
differ  in  the  two  sexes,  women  being  more  frequently  affected 
with  flatulence  and  vomiting  and  men  with  pain  and  acidity. 

(c)  Influence  of  the  Type  of  the  Lung  Disease. — The  most 
typical  instances  of  dyspepsia  are  encountered  in  that  variety 
of  pulmonary  tuberculosis  which  commences  insidiously  and 
progresses  slowly. 

In  cases  of  miliary  disease,  gastric  symptoms  are  usually 
present  at  the  outset,  and,  according  to  the  statements  of 
Pollock,  almost  every  case  of  acute  phthisis  is  accompanied 
by  troublesome  indigestion.  But  in  both  these  varieties  of 
the  lung  disease,  the  rapid  progress  of  the  primary  mischief 
soon  produces  a  train  of  symptoms  so  severe  as  to  completely 
eclipse  those  arising  from  a  functional  disturbance  of  the 
stomach;  and  it  is  not  surprising  that  a  patient,  whose  main 
desire  is  to  gain  relief  for  his  laboured  respiration  or  respite 
from  his  cough,  should  neglect  such  trifling  symptoms  as 
flatulence  and  acidity.  On  the  other  hand,  in  the  more  chronic 
forms  of  the  complaint,  and  when  the  cough  and  dyspnoea 
are  as  yet  undeveloped,  the  patient,  is  apt  to  concentrate  his 


SYMPTOMS.  369 

attention  upon  his  increasing  failure  of  strength,  and  will 
consequently  blame  the  deficient  powers  of  digestion  as  the 
principal  cause  of  his  weakness  and  loss  of  flesh  and  feel 
most  acutely  any  symptoms  which  may  arise  during  the  process 
of  food  assimilation. 

{d)  The  Existence  of  Previous  Dyspepsia. — Among  my 
series  of  cases,  72  per  cent,  of  the  females  and  17  per  cent,  of 
the  males  had  suffered  at  one  time  or  another  from  moderate 
or  severe  indigestion;  and  since  it  has  already  been  shown  that 
females  are  more  prone  to  exhibit  the  symptoms  of  dyspepsia 
in  early  phthisis  than  members  of  the  opposite  sex,  it  would 
seem  that  a  previous  attack  of  indigestion  predisposed  to  the 
complaint  in  question. 

Sjnnptoms. — Pain. — This  forms  one  of  the  most  constant 
features  of  the  disease  and  is  present  to  a  noticeable  degree 
in  about  92  per  cent,  of  all  cases. 

It  is  usually  described  as  a  sensation  of  weight  or  uneasiness 
rather  than  actual  pain,  but  in  some  cases  a  considerable 
amount  of  suffering  is  experienced.  The  symptom  usually 
makes  its  appearance  almost  immediately  after  the  meal,  but 
it  may  be  delayed  for  half  an  hour  to  two  hours.  At  the  com- 
mencement of  the  disease  pain  may  only  follow  the  evening 
meal  and  then  only  occasionally;  but  as  the  disorder  progresses 
it  gradually  becomes  more  constant.  In  the  majority  of  the 
cases  the  sensation  is  referred  to  the  chest  rather  than  to  the 
abdomen,  and  often  appears  to  be  situated  under  the  lower 
end  of  the  sternum  slightly  to  its  left  side.  In  other  instances, 
it  is  the  cardiac  region  which  is  more  immediately  affected,  and 
when  pain  in  this  locality  is  combined  with  attacks  of  palpi- 
tation, the  patient  will  often  seek  advice  on  account  of  a 
supposititious  affection  of  the  heart.  The  cause  of  the  pain 
varies  with  the  secretory  activity  of  the  stomach.  When,  as 
is  usually  the  case,  the  production  of  hydrochloric  acid  is 
diminished,  the  discomfort  experienced  after  meals  is  due  to 
stagnation  and  fermentation  of  the  food.  In  other  cases 
24 


370  THE    INITIAL    DYSPEPSIA. 

hyperacidity  exists  and  the  symptom  is  then  attributable  to 
irritation  of  the  gastric  mucous  membrane. 

Vomiting. — This  usually  shows  itself  in  the  first  instance 
when  the  patient  arises  from  bed  in  the  morning,  and  is  preceded 
by  a  tickling  sensation  in  the  throat  and  severe  cough.  Retching 
follows  directly  upon  a  violent  expiratory  effort  which  is 
necessary  to  dislodge  and  expel  a  small  quantity  of  sticky 
secretion  from  the  pharynx  or  bronchial  tubes,  and  if  the 
stomach  happens  to  contain  any  food  or  an  excess  of  mucus, 
this  is  rejected  at  the  same  time.  Occasionally,  when  the 
retching  has  been  severe,  I  have  known  a  small  quantity  of 
bilious  or  even  blood-stained  fluid  to  be  vomited,  but  this  is 
rarely  encountered.  It  is  to  be  noticed  that  the  attack  is 
neither  preceded  nor  accompanied  by  nausea,  giddiness,  or 
faintness,  and  possesses  no  tendency  to  spontaneous  recurrence, 
while  the  patient  is  often  able  to  partake  of  breakfast  without 
further  discomfort. 

In  other  instances,  or  at  a  later  period  in  the  same  case, 
another  variety  of  vomiting  may  occur.  At  first  sight  this 
appears  to  be  directly  excited  by  the  ingestion  of  food,  and 
takes  place  most  frequently  after  the  evening  meal.  Careful 
observation,  however,  usually  shows  that  in  this  case,  also, 
the  vomiting  is  preceded  and  caused  by  cough.  In  severe 
cases  of  this  kind,  every  attempt  to  partake  of  food  is  followed 
by  an  attack  of  coughing  which  terminates  in  vomiting,  and 
the  patient,  though  he  feels  himself  growing  steadily  weaker, 
fears  to  indulge  his  appetite  on  account  of  the  discomfort 
which  invariably  follows. 

Disorders  of  Appetite. — In  this  variety  of  dyspepsia,  there 
is  usually  a  marked  repugnance  to  all  kinds  of  fat,  that  be- 
longing to  mutton,  beef,  veal,  or  pork  being  epecially  dis- 
tasteful. Thus,  Hutchinson  found  that  71  per  cent,  of  his 
cases  of  phthisis  dishked  all  kinds  of  fats;  33  per  cent,  could 
take  it  in  small  quantities,  while  only  5  per  cent,  liked  it. 
Among  my  own  cases,  marked  aversion  from  fat  was  noticed 


SYMPTOMS.  371 

in  64  per  cent. ;  of  this  number  the  dislike  had  been  acquired 
at  the  commencement  of  the  dyspepsia  in  39  per  cent.,  but  had 
existed  throughout  life  in  61  per  cent.  It  is  noteworthy  that 
in  the  latter  class  the  repugnance  to  fatty  substances  had 
increased  with  the  development  of  the  dyspepsia,  and  that 
in  the  majority  of  the  cases  one  or  more  members  of  the 
patient's  family  had  succumbed  to  phthisis. 

These  results  are  in  close  accord  with  the  statements  of 
Edward  Smith,  who  found  that  44  per  cent,  of  his  cases  of 
phthisis  dishked  all  kinds  of  fat,  while  in  only  37.7  per  cent, 
was  it  palatable.  This  writer  also  states  that  28.8  per  cent, 
specially  disliked  bacon  fat,  6 . 6  per  cent,  butter,  and  only  o .  23 
per  cent.  milk.  Many  of  my  patients,  on  the  contrary,  were 
able  to  eat  bacon  when  they  possessed  the  greatest  abhorrence 
of  other  kinds  of  fat  meat. 

In  some  cases,  during  the  early  stages  of  the  gastric  disorder, 
saccharine  substances  are  apt  to  disagree  and  therefore  become 
distasteful.  Among  the  cases  investigated  by  Hutchinson,  29 
per  cent,  disliked  sugar  of  all  kinds,  and  about  8  per  cent,  of 
these  had  acquired  the  aversion  after  the  onset  of  the  pulmonary 
disease.  Dobell  found  that  sugar  disagreed  in  37  per  cent,  of 
the  cases  he  examined.  According  to  my  experience,  about 
20  per  cent,  of  the  female  sufferers  from  this  complaint  and 
7  per  cent,  of  the  male  have  an  objection  to  sweet  articles  of 
food,  but  in  the  majority  a  want  of  relish  was  more  apparent 
than  actual  aversion,  while  in  many  the  symptom  had  existed 
since  birth.  On  the  whole,  it  would  seem  that  in  about  7  per 
cent,  of  all  cases  the  patient  loses  his  relish  for  saccharine  sub- 
stances when  the  first  symptoms  of  the  gastric  derangement 
manifest  themselves.  In  rare  instances  alcohol  appears  to  dis- 
agree, and  a  man  who  had  previously  indulged  freely  in  wine 
or  spirits  will  lose  all  desire  for  these  beverages  or  even  actively 
dislike  them.  This  symptom,  however,  is  by  no  means  com- 
mon and  is  more  frequently  encountered  in  private  than  in 
hospital  practice. 


372  THE   INITIAL   DYSPEPSIA. 

When  the  dyspepsia  has  become  well  established,  many  pa- 
tients develop  a  craving  for  certain  substances  toward  which 
they  had  previously  been  either  indifferent  or  ill-disposed.  It  is 
usually  the  acid  or  bitter  materials  which  enjoy  the  greatest 
popularity,  and  raw  fruit,  lemons,  or  sour  oranges  are  de- 
voured with  avidity.  Occasionally  these  tastes  become  decid- 
edly morbid,  and  the  patient  will  often  consume  the  contents  of 
a  vinegar  cruet  during  a  single  meal  or  may  even  drink  the 
acetous  fluid  out  of  a  spoon.  Sometimes  jam  is  devoured  in. 
large  quantities  and  with  extreme  relish  when  nothing  else 
can  be  found  to  tempt  the  capricious  appetite. 

Reflex  Cough. — This  is  an  exceedingly  common  symptom  of 
the  dyspepsia  of  early  phthisis  and  has  long  attracted  attention 
under  the  name  of  "stomach  cough,"  or  "toux  gastrique." 

Soon  after  a  meal,  especially  if  the  food  taken  has  been 
somewhat  excessive  in  amount  or  difficult  of  digestion,  the 
patient  is  seized  with  a  severe  attack  of  coughing  which  usually 
terminates  in  the  expulsion  of  the  contents  of  the  stomach. 
Sometimes  the  cough  comes  on  without  warning,  but  usually 
it  is  preceded  by  a  sense  of  irritation  at  the  back  of  the  throat 
or  base  of  the  tongue.  The  explanation  of  this  phenomenon 
is  probably  to  be  found  in  an  increased  sensibihty  of  the  gas- 
tric mucous  membrane  associated  with  an  abnormal  excita- 
bility of  the  respiratory  centre. 

Flatulence  exists  in  72  per  cent,  of  the  cases,  and  is  rather 
more  frequent  in  women  (80  per  cent.)  than  in  men  (62  per 
cent.).     Acidity  is  present  in  45  per  cent. 

Constipation  is  an  almost  invariable  symptom  of  the  com- 
plaint, and  generally  proves  rebellious  to  treatment.  The 
evacuations  are  pale  and  fcetid  and  contain  an  excess  of  un- 
digested food.  Occasionally  the  faeces  are  coated  with  a  thick 
layer  of  mucus  which  induces  the  patient  to  believe  that  he  is  the 
subject  of  worms.  Attacks  of  diarrhoea  are  apt  to  occur  from 
time  to  time,  and  become  frequent  as  the  disease  of  the  lung 
shows  a  tendency  to  the  formation  of  cavities. 


CHEMISTRY    OF    DIGESTION.  373 

The  tongue  is  large,  flabby,  and  often  indented  along  its 
margins  by  the  teeth.  The  buccal  secretions  are  acid,  and 
the  incisor  and  canine  teeth  often  undergo  a  rapid  form  of 
decay.  Some  patients  complain  of  extreme  thirst  at  night- 
time, but  this  is  seldom  a  noticeable  feature  of  the  complaint. 

Ancemia  is  always  present  to  a  marked  degree,  especially 
in  women,  and  the  catamenia  are  scanty  and  irregular,  while 
not  infrequently  they  are  entirely  suppressed. 

Occasionally  the  skin  of  the  neck,  breast,  axillae,  or  that 
in  the  region  of  the  cervical  spine  presents  an  excess  of  pig- 
ment, and  this,  if  it  be  combined  with  gastric  phenomena 
of  a  severe  character  and  extreme  weakness,  may  lead  to  a 
mistaken  diagnosis  of  Addison's  disease. 

The  degree  of  fever  which  accompanies  the  pulmonary 
disease  does  not  appear  to  exercise  any  decided  influence 
upon  the  severity  of  the  gastric  complaint.  Special  observations 
made  on  twenty-seven  cases  with  reference  to  this  point 
showed  that  seventeen  exhibited  little  or  no  pyrexia  during  the 
day,  while  the  remaining  ten  suffered  from  continued  fever. 

Gastrectasis. — Among  my  122  cases  of  dyspepsia  associated 
with  physical  signs  of  recent  consolidation  of  the  lung,  twenty- 
eight,  or  about  23  per  cent.,  presented  some  evidence  of  en- 
largement of  the  stomach,  the  lower  border  of  the  organ  ex- 
tending as  far  as  the  navel  or  below  it,  while  in  four  instances 
the  degree  of  gastrectasis  was  very  considerable.  It  is  prob 
able,  therefore,  that  about  20  per  cent,  of  the  cases  exhibit 
some  degree  of  dilatation  of  the  stomach.  This  estimate 
falls  far  short  of  that  of  Marfan,  who  was  able  to  discover 
either  atony  or  dilatation  of  the  organ  in  every  case  which 
he  examined. 

Chemistry  of  Digestion. — Klemperer  found  that  in  the 
majority  of  his  cases  of  early  phthisis,  the  gastric  secretion 
was  either  normal  or  somewhat  increased,  and  Immermann 
and  Schetty  have  arrived  at  similar  conclusions.     Brieger, 


374  THE    TERMINAL   DYSPEPSIA. 

on  the  other  hand,  states  that  in  incipient  phthisis  the  secretion 
of  hydrochloric  acid  is  practically  normal,  while  in  moderate 
cases  of  the  disease  it  is  reduced  in  60  per  cent,  normal  in 
33  per  cent.,  and  absent  in  6.6  per  cent.  Hildebrandt  con- 
siders that  the  formation  of  the  acid  depends  upon  the  tem- 
perature of  the  body,  since  he  found  it  existent  in  apyretic 
cases,  but  absent  in  those  accompanied  by  fever.  He  also 
noted  the  reappearance  of  the  acid  when  the  temperature 
had  been  reduced  by  antipyrin.  These  observations  have 
not  been  confirmed  by  Schetty. 

The  motor  power  of  the  stomach  diminishes  when  the 
tuberculous  deposits  in  the  lung  undergo  softening,  and, 
according  to  Brieger,  it  is  always  reduced  when  the  secretion 
of  hydrochloric  acid  fails. 

Course  and  Termination. — The  course  of  the  initial 
dyspepsia  is  very  variable,  and,  as  a  rule,  its  symptoms  are 
gradually  replaced  by  those  which  attend  the  terminal 
stage  of  the  pulmonary  complaint.  There  are,  however, 
three  facts  of  importance  connected  with  this  variety  of 
dyspepsia  in  phthisis.  In  the  first  place,  the  indigestion  may 
constitute  the  sole  symptom  of  the  lung  complaint,  and  the 
tuberculous  mischief  may  proceed  to  the  formation  of  large 
cavities  without  giving  rise  either  to  cough  or  expectoration. 
Secondly,  the  dyspepsia  often  amends  or  alters  in  type  as 
the  phthisis  progresses;  the  pain  and  vomiting  either  subsiding 
when  cough  and  night-sweats  become  troublesome,  or  the 
symptoms  of  myasthenia  of  the  stomach  and  bowel  are 
replaced  by  those  of  chronic  gastroenteritis.  Lastly,  if  the 
pulmonary  complaint  becomes  arrested  the  dyspepsia  usually 
disappears. 

(ii)  The  Terminal  Dyspepsia. 

The  advent  of  the  final  stage  of  the  tubercular  disease  is 
often  heralded  by  a  recurrence  of  the  dyspepsia  which  had 
proved  so  troublesome  a  symptom  at  the  onset  of  the  lung 


SYMPTOMS.  375 

complaint.  Once  more  the  patient  begins  to  experience 
discomfort  after  his  meals,  with  nausea  and  occasional  vomiting; 
and  attacks  of  diarrhoea  come  on  at  short  intervals  and  prove 
extremely  exhausting.  As  a  rule,  this  variety  of  dyspepsia 
does  not  attract  much  attention,  being  completely  overshadowed 
by  the  pulmonary  symptoms;  but  sometimes  the  cough  and 
expectoration  remain  latent,  and  the  gastric  disorder  may  con- 
stitute the  sole  cause  of  complaint.  In  several  instances  which 
have  come  under  my  notice,  phthisis  was  never  suspected 
until  a  few  days  before  death,  while  in  others  the  lungs  were 
found  to  be  riddled  with  cavities  at  the  necropsy  to  the  great 
astonishment  of  the  medical  attendant,  who,  owing  to,  the 
absence  of  the  ordinary  pulmonary  symptoms,  had  regarded 
the  disease  as  simple  gastritis. 

Among  my  316  cases  of  pulmonary  tuberculosis  which 
presented  the  signs  of  excavation,  135,  or  42.5  per  cent.,  suf- 
fered from  dyspepsia  of  sufficient  severity  to  attract  notice. 
Women  appear  to  be  more  liable  to  the  complaint  than  men, 
for,  while  62  per  cent,  of  the  female  subjects  of  chronic  phthisis 
exhibited  symptoms  of  a  gastric  derangement,  only  25  per  cent, 
of  the  males  suffered  in  a  similar  manner. 

Sjrmptoms. — The  appetite  invariably  diminishes  with  the 
progress  of  the  disease.  At  first  it  is  capricious,  and  the  patient 
may  exhibit  the  same  fanciful  tastes  as  in  the  earlier  stages  of 
phthisis.  Occasionally  the  signs  of  a  false  appetite  are  present 
in  a  very  marked  degree,  and  a  feeling  of  intense  hunger  will 
be  suddenly  replaced  by  a  loathing  of  food  as  soon  as  a  few 
mouthfuls  have  been  swallowed.  As  the  complaint  advances 
the  anorexia  becomes  complete,  but  in  rare  instances  the  patient 
may  retain  his  reHsh  for  food  until  the  last,  or  may  even  suffer 
from  extreme  hunger.  As  a  rule,  the  distaste  for  fat  persists 
during  the  whole  course  of  the  pulmonary  complaint,  and 
eventually  even  butter  and  cod-liver  oil  cannot  be  tolerated 
owing  to  the  nausea  and  discomfort  which  are  apt  to  follow 
their  ingestion.     It  is  a  curious  fact,   however,   that   many 


376  THE  TERMINAL  DYSPEPSIA. 

patients  appear  to  lose  their  antipathy  to  meat  fat  as  the  final 
stage  of  the  disease  approaches,  and  a  few  even  acquire  a 
certain  amount  of  relish  for  some  varieties. 

About  57  per  cent,  of  my  cases  suffering  from  this  form 
of  dyspepsia  were  unable  to  eat  fat,  and  8  per  cent,  disliked 
sugar. 

Thirst  is  a  frequent  though  not  invariable  symptom.  It 
may  exist  only  at  meal  times,  but  it  is  more  commonly  com- 
plained of  in  the  intervals  of  taking  food.  The  sensation  is 
usually  relieved  most  readily  by  drinking  cold  water,  but 
sometimes  hot  or  acid  liquids  are  preferred. 

Painful  sensations  at  the  epigastrium,  occurring  either 
spontaneously  or  as  a  result  of  an  effort  of  digestion,  are  com- 
paratively rarely  encountered  in  this  form  of  dyspepsia. 
Among  my  135  cases  of  the  disorder,  only  fifty-six,  or  41  per 
cent,  exhibited  this  symptom. 

When  it  occurs,  the  pain  usually  shows  itself  within  five  to 
thirty  minutes  after  the  meal,  and  varies  from  a  sense  of  oppres- 
sion and  discomfort  to  one  of  intense  burning  over  the  epigastric 
and  cardiac  regions,  or  between  the  shoulders.  Deep  pressure 
with  the  hand  generally  tends  to  increase  the  suffering,  but 
sometimes  it  affords  distinct  relief. 

Contrary  to  the  usual  statement  that  vomiting  is  a  constant 
feature  of  the  gastritis  of  phthisis,  only  32  per  cent,  of  my 
cases  exhibited  this  symptom.  Occasionally  an  attack  of 
coughing  occurs  shortly  after  a  meal,  and  terminates  in  the 
rejection  of  the  contents  of  the  stomach,  but  this  accident  is 
much  less  frequent  than  in  the  earlier  stages  of  the  pulmonary 
disease. 

When  vomiting  constitutes  a  well-marked  feature  of  the 
complaint,  it  occurs  at  irregular  intervals  and  often  in  the  early 
morning  before  any  food  has  been  taken.  Nausea  is  an  al- 
most constant  symptom  and  may  persist  for  many  hours  after 
the  emesis.  The  ejecta  are  sour  and  contain  an  excess  of 
mucus,    and   occasionally   consist   entirely   of   this   material. 


SYMPTOMS.  377 

Hsematemesis  is  extremely  rare,  but  occasionally  small  quan- 
tities of  blood  are  vomited  during  a  severe  attack  of  retching. 

Flatulence  and  acidity  were  noted  in  about  30  per  cent,  of 
the  cases,  and  usually  co-existed  with  nausea  and  vomiting. 

The  bowels  are  usually  irregular  in  their  action  at  the 
commencement  of  the  complaint,  periods  of  constipation 
alternating  with  sharp  attacks  of  diarrhoea.  Toward  the  last, 
however,  the  bowels  are  relieved  every  hour  or  two,  and  the 
exhaustion  which  arises  from  this  symptom  materially  hastens 
the  fatal  termination  of  the  case. 

In  the  early  stages  the  tongue  is  usually  redder  than  normal 
and  presents  a  bright  red  tip  and  a  dorsum  covered  in  a  patchy 
manner  with  yellow  fur.  Later  on  the  surface  of  the  organ 
acquires  a  morbidly  red  and  shining  appearance  or  it  becomes 
dry  in  the  centre  with  aphthous  patches  along  its  tip  and 
edges. 

Physical  Examination. — The  exact  determination  of  the 
outline  of  the  stomach  in  these  cases  is  often  a  matter  of  some 
difficulty,  owing  to  the  rigid  state  of  the  abdominal  wall  and 
the  pain  which  accompanies  palpation  and  percussion. 

In  cases  of  moderate  severity  the  stomach  almost  always 
exhibits  some  evidence  of  dilatation  and  the  lower  border 
may  be  found  to  reach  as  far  as  the  navel  or  slightly  below  it. 
As  the  pulmonary  disease  advances  the  area  occupied  by  the 
organ  becomes  progressively  increased,  and  at  a  late  stage  the 
greater  curvature  may  extend  several  inches  below  the  level  of 
the  umbilicus  or  even  reach  as  far  as  the  pubes. 

Out  of  317  cases  of  chronic  phthisis  associated  with  vomicae, 
I  found  that  273,  or  about  86  per  cent.,  showed  signs  of  dilata- 
tion of  the  stomach,  and  in  every  one  of  the  135  cases  which 
suffered  from  dyspeptic  symptoms  the  characteristic  splash 
could  be  obtained  at  or  below  the  level  of  the  navel. 

Chemistry  of  Digestion. — The  peptic  ferment  continues  to 
be  secreted  by  the  stomach  until  the  mucous  membrane  has 
received  permanent  damage   from  the   attacks   of  subacute 


37^  THE    TERMINAL   DYSPEPSIA. 

inflammation  which  are  apt  to  occur  during  the  final  stage  of 
pulmonary  tuberculosis,  and  an  artificial  juice  prepared  from 
these  cases  usually  exhibits  a  considerable  degree  of  activity. 
When,  however,  the  secreting  structures  have  become  the  seat 
of  a  diffuse  fibrosis  or  of  lardaceous  disease,  the  artificial  juice 
is  found  to  exert  little  or  no  action  upon  fibrin  or  albumen. 

With  regard  to  the  secretion  of  hydrochloric  acid,  there 
is  still  a  considerable  divergence  of  opinion.  Schetty  states 
that  he  could  discover  no  marked  alteration  in  the  quantity  of 
the  free  acid  in  the  various  cases  which  he  examined,  while 
Immermann  was  able  to  detect  its  presence  even  in  advanced 
cases  of  phthisis  accompanied  by  severe  pyrexia.  Hayem  and 
Einhom  seem  to  regard  the  secretion  as  extremely  irregular, 
while  Klemperer  found  that  free  acid  gradually  disappeared 
from  the  contents  of  the  stomach  as  the  pulmonary  disease 
progressed.  In  thirty-four  cases  of  advanced  phthisis  in- 
vestigated by  Brieger,  the  hydrochloric  acid  was  normal  in 
1 6  per  cent,  absent  in  9.6  per  cent.,  and  diminished  in  the 
remainder. 

When  the  mucous  membrane  of  the  stomach  is  attacked  by 
lardaceous  disease,  the  secretion  of  hydrochloric  acid  rapidly 
fails  and  soon  ceases  altogether  (Cahn  and  von  Mering,  Edin- 
ger,  Riegel). 

The  motor  power  of  the  stomach  always  shows  signs  of 
weakness  in  these  cases  (Klemperer),  and  absorption  as  deter- 
mined by  the  method  of  Penzoldt  is  invariably  delayed. 

In  almost  every  case  gastric  fermentation  is  active,  and  its 
various  products  can  easily  be  recognised  by  appropriate 
means. 

Course  and  Termination. — When  once  the  dyspeptic 
symptoms  ha^•e  shown  themselves  in  a  case  they  usually 
persist  until  death.  The  tongue  becomes  dry  and  is  attacked 
with  thrush,  the  discomfort  after  food  gradually  increases,  the 
anorexia  becomes  complete,  and  the  patient  succumbs  either  to 
extreme  exhaustion  or  to  some  accident  connected  with  the 


DISEASES    OF    THE   HEART.  379 

pulmonary  complaint.  It  is,  however,  important  to  note  that 
if  the  tuberculous  disease  undergoes  temporary  arrest  the  gas- 
tric phenomena  usually  exhibit  a  corresponding  remission, 
while  the  permanent  cure  of  the  phthisis  is  almost  invariably 
followed  by  diminution  of  the  dyspepsia.  This  latter  phe- 
nomenon is  frequently  observed,  and  I  have  the  notes  of 
several  cases  of  chronic  fibroid  phthisis  of  eight  to  twelve  years' 
duration,  in  which  the  main  symptoms  of  indigestion  were 
completely  absent,  though  the  stomach  still  showed  signs  of 
considerable  dilatation. 

Treatment. — This  should  be  conducted  upon  the  hnes  laid 
down  for  cases  of  chronic  gastritis  (Chap.  IV) .  When  vomiting, 
after  meals  is  a  prominent  symptom  of  the  complaint,  the 
patient  should  be  kept  in  bed  and  fed  principally  upon  milk. 
Soured  milk,  kefir,  and  koumiss  are  often  useful.  Greasy 
and  fatty  foods  almost  always  excite  disgust,  and  should 
therefore  be  used  with  caution  or  even  withheld  altogether. 
In  like  manner,  highly  spiced  or  sweet  articles  of  diet  usually 
prove  unpleasant.  The  vomiting  from  reflex  cough  is  best 
combated  by  the  administration  of  a  bismuth  mixture  con- 
taining a  small  quantity  of  morphine  or  nepenthe  or  by  the  use 
of  codeine  jelly.  Occasionally  a  tumblerful  of  hot  water  taken 
before  meals  reduces  the  liabiHty  to  this  symptom.  Vomiting 
after  meals  must  be  treated  by  gastric  antiseptics  and  alkalies. 
Constipation  always  requires  consideration,  and  the  action 
of  the  bowels  should  be  regulated  by  small  doses  of  mercury 
and  chalk,  cascara  sagrada,  or  by  the  aloes  and  iron  pill. 
Diarrhoea  may  be  controlled  by  the  use  of  sahcylate  of  bismuth, 
resorcine,  or  other  intestinal  antiseptics. 

(3)  DISEASES  OF  THE  HEART. 

In  uncomplicated  cases  of  valvular  disease  the  functions 
of  the  stomach  are  rarely  disturbed,  and,  as  a  rule,  the  secretion 
of  hydrochloric  acid  continues  normal;  but  when  dilatation 
of  the  heart  occurs  the  portal  system  becomes  congested  and 


380  DISEASES    OF    THE   HEART. 

the  stomach  suffers  in  consequence.  After  death  from  gradual 
cardiac  failure,  the  stomach  appears  to  be  much  thickened 
and  heavier  than  usual,  while  its  inner  surface  is  purple  in 
colour  and  covered  by  a  thick  layer  of  tenacious  mucus. 
The  removal  of  the  latter  shows  that  the  rugae  of  the  organ 
are  increased  in  size  and  that  the  mucous  membrane  is  studded 
with  haemorrhages  which  vary  from  the  size  of  a  millet  seed  to 
that  of  a  two-shilling  piece,  while  here  and  there  antemortem 
digestion  of  these  infiltrated  areas  has  given  rise  to  superficial 
ulcers.  Occasionally  the  surface  is  rough  and  gritty,  owing 
to  the  deposition  of  phosphatic  salts.  Microscopical  ex- 
amination reveals  an  excessive  congestion  of  all  the  veins 
and  capillaries  of  the  organ,  especially  of  those  which  ramify 
between  the  peptic  glands  and  in  the  submucous  coat.  The 
pressure  exerted  by  these  enlarged  blood  vessels  causes  the 
gastric  tubules  to  present  an  irregular,  compressed,  or  twisted 
appearance,  while  in  some  parts  of  the  section  their  outlines 
are  quite  obscured  by  interstitial  haemorrhages.  Both  the 
central  and  the  parietal  cells  are  swollen,  their  nuclei  are 
obscured,  and  occasionally  fatty  degeneration  of  their  proto- 
plasm can  be  detected  (S.  Fen  wick). 

The  gastric  secretion  varies  with  the  degree  of  portal  con- 
gestion. During  the  early  stages  of  cardiac  failure  free  hydro- 
chloric acid  can  usually  be  detected  in  the  contents  of  the 
viscus  after  a  test-meal,  but  is  absent  if  a  large  quantity 
of  food  has  been  administered.  Thus,  Hueffler  found  an  ab- 
sence of  the  free  acid  after  a  large  test-meal,  while  Einhorn, 
Adler,  and  Stern,  who  employed  a  light  test  breakfast,  were 
able  to  demonstrate  its  presence  in  two-thirds  of  their  cases. 
Of  the  twenty-three  examples  of  failure  of  the  heart  examined 
by  van  Valzah  and  Nisbet,  five  showed  normal  secretion; 
thirteen,  diminished  secretion;  and  five,  a  complete  absence  of 
free  hydrochloric  acid.  As  the  acid  diminishes  the  peptic 
and  rennet  ferments  also  fail,  but  these,  like  the  acid,  become 
augmented  if  the  cardiac  muscle  regains  its  normal  tone. 


SYMPTOMS.  381 

In  advanced  cases  the  motility  of  the  stomach  is  impaired, 
its  absorptive  capacity  is  limited,  and  stagnation  of  the  food 
occurs.  Of  the  various  secondary  fermentations  which  ensue, 
that  which  gives  rise  to  an  acetone  odour  of  the  breath  and 
the  formation  of  di-acetic  acid  in  the  stomach  is  the  most  inter- 
esting and  important,  since  its  presence  almost  invariably 
denotes  the  advent  of  anorexia  and  gastric  intolerance. 

Symptoms. — Even  when  compensation  is  complete,  the 
subjects  of  vahTdar  disease  usually  erperience  a  sense  of 
oppression  at  the  chest  and  flatulence  after  meals,  which 
become  gradually  more  severe  as  the  right  side  of  the  heart 
undergoes  dilatation.  In  such  cases  sudden  and  excessive  dis- 
tention of  the  stomach  and  intestines  is  apt  to  occur  during 
digestion,  which  has  the  effect  of  displacing  the  heart  upward 
and  causing  faintness  or  even  fatal  syncope.  In  other  in- 
stances, violent  palpitation  is  experienced  after  each  meal, 
accompanied  perhaps  by  giddiness  and  marked  irregularity 
of  the  pulse.  x\t  a  more  advanced  stage  of  the  cardiac  com- 
plaint, anorexia  usually  develops  and  the  patient  may  express 
the  greatest  loathing  of  nourishment  of  any  kind.  This 
symptom  is  one  of  considerable  importance,  since  it  not  only 
leads  to  voluntary  starA^ation  with  consequent  enfeeblement 
of  the  heart's  action,  but  is  often  an  indication  of  impending 
death. 

In  almost  every  instance  vomiting  ensues  from  the  con- 
gestion and  secondary  inflammation  of  the  stomach,  and  has 
the  effect  of  preventing  both  the  administration  of  food  and 
also  of  digitahs  and  other  medicines.  When  emesis  is  a 
frequent  symptom,  the  skin  and  conjunctivse  are  usually 
slightly  jaundiced,  the  breath  possesses  the  odour  character- 
istic of  acetone,  and  the  urine  is  greatly  reduced  in  amount. 
Giddiness  and  somnolence  are  constantly  complained  of,  sleep 
is  fitful,  and  the  bowels  are  irregular  in  their  action.  The 
vomited  material  usually  consists  of  bile-stained  mucus,  but 
occasionally  it  contains  traces  of  altered  blood,  while  in  rare 


382  DISEASES    OF    THE    LIVER. 

instances  a  severe  or  even  fatal  haematemesis  may  occur.  On 
examination  of  the  abdomen  the  epigastrium  is  found  to  be 
distended  and  tender  to  pressure,  and  the  stomach  slightly 
dilated.  According  to  Leared,  the  stools  often  contain  an 
excess  of  fat. 

Treatment. — Digitalis  is  invariably  required,  but  if 
vomiting  is  severe  the  drug  should  be  given  in  the  form  of  a 
pill  or  administered  by  the  rectum.  On  the  other  hand,  if 
the  vomiting  develops  during  a  course  of  treatment  by  digitalis, 
the  toxic  effects  of  the  drug  must  be  borne  in  mind,  and  a 
mixture  of  carbonate  of  sodium  and  rhubarb  should  be  given 
for  a  few  days  with  a  brisk  mercurial  purge.  Excessive 
flatulence  after  meals  may  be  combated  by  the  adm^inistration 
of  an  alkaline  medicine  containing  carbolic  acid  and  a  diffusible 
stimulant,  and  in  the  dangerous  attacks  of  syncope  that  occur 
during  digestion  an  enema  of  turpentine  is  often  of  great 
value.  In  other  respects  the  treatment  is  identical  with  that 
of  chronic  gastritis  (Chap.  IV). 

(4)  DISEASES  OF  THE  LIVER. 

The  anatomical  and  physiological  relationships  that  exist 
between  the  liver  and  the  stomach  are  sufl&cient  to  explain 
the  frequency  with  which  the  digestive  functions  are  deranged 
in  hepatic  diseases. 

Obstruction  of  the  portal  circulation,  such  as  occurs  from 
the  pressure  of  a  tumour,  thrombosis  of  the  vein,  or  chronic 
perihepatitis,  produces  the  same  effects  upon  the  stomach  as 
chronic  dilatation  of  the  heart  and  leads  to  a  gradual  failure 
of  the  gastric  secretion.  Simple  enlargement  of  the  liver  is 
a  frequent  cause  of  a  vertical  displacement  of  the  stomach, 
whereby  motor  insufficiency  with  its  attendant  evils  is  induced 
(Chap.  VI).  Lardaceous  disease  is  associated  with  a  similar 
condition  of  the  gastric  mucosa  and  anacidity  of  the  secretion. 
Hypertrophic  cirrhosis  is  accompanied  by  discomfort  after 
meals,  flatulence,  acidity,  constipation,  and  other  symptoms 


DISEASES    OF    THE    KIDNEYS   AND    URINARY    ORGANS.     ;^82, 

that  ensue  from  the  coexistence  of  hyperacidity  (van  Valzah). 
Gall-stones  are  attended  by  hyperacidity  in  about  60  per  cent, 
of  all  cases,  and  in  even  a  larger  percentage  by  hypersecretion. 
During  an  attack  of  the  colic  the  first  few  specimens  of  vomit 
usually  contain  free  hydrochloric  acid,  but  subsequently  they 
consist  entirely  of  bile-stained,  alkahne  mucus.  As  a  rule,  the 
hyperacidity  diminishes  or  disappears  after  the  elimination  of 
the  stone,  while  its  persistence  usually  indicates  that  other  calculi 
exist  in  the  gall-bladder  or  biliary  ducts.  Hyperacidity  is 
also  frequently  met  with  in  cases  of  catarrhal  jaundice. 

Atrophic  cirrhosis  of  the  liver  is  invariably  associated 
with  chronic  interstitial  and  parenchymatous  gastritis,  which 
owes  its  origin  to  the  same  cause  as  the  hepatic  disease. 
Subsequently  the  inflammation  of  the  stomach  becomes  com- 
plicated by  the  venous  congestion  arising  from  portal  obstruc- 
tion, and  not  infrequently  severe  haemorrhage  ensues  from 
the  varicose  veins  around  the  cardiac  orifice. 

The  organic  affections  of  the  stomach  that  arise  from 
disease  of  the  liver  include  stenosis  of  the  pylorus  or  duodenum 
from  adhesion  of  the  gall-bladder  and  obstruction  to  the  exit 
of  food  into  the  intestine  from  pressure  of  a  hydatid,  gumma, 
or  cancerous  tumour.  In  the  former  case  the  signs  of  gastric 
dilatation  are  accompanied  by  chronic  hypersecretion,  while  in 
the  latter  the  characters  of  the  gastric  juice  vary  with  the 
nature  of  the  primary  complaint. 

(5)  DISEASES  OF  THE  KIDNEYS  AND  URINARY  ORGANS. 

Inflammation  of  the  kidneys  is  always  accompanied  by  a 
similar  affection  of  the  stomach  and  intestines,  the  histology 
of  which  varies  with  the  type  of  the  renal  disease.  Thus,  in 
acute  parenchymatous  nephritis  the  gastric  tubules  as  well  as 
the  glands  of  the  intestine  are  found  to  be  swollen,  irregular, 
and  filled  with  granular  and  disintegrated  cells.  With  a  large 
white  kidney  a  chronic  inflammation  of  the  glandular  structures 
of  the  stomach  and  bowel  is  encountered,  and  the  peptic  cells 


384    DISEASES    OF   THE    KIDNEYS  AND   URINARY   ORGANS. 

exhibit  fatty  degeneration,  while  in  cases  of  chronic  intersti- 
tial nephritis  the  mucous  membrane  of  the  gastrointestinal 
tract  undergoes  a  form  of  fibrosis  owing  to  an  inflammatory 
thickening  of  the  interglandular  connective  tissue.  Similar 
changes  to  these  occur  in  the  sweat  glands  of  the  skin  (S. 
Fen  wick).  Occasionally  small  haemorrhages  appear  in  the 
mucous  membrane  of  the  stomach,  or  superficial  ulcers  of 
considerable  size  may  develop.  Sloughing  ulcers  are  also 
met  with  in  the  colon.  The  cause  of  this  gastroenteritis  in 
kidney  disease  is  to  be  found  in  the  vicarious  excretion  of  urea 
and  other  poisons  by  the  digestive  organs,  and  in  almost  every 
case  of  the  renal  complaint  urea  may  be  detected  in  the  con- 
tents of  the  stomach  and  in  the  stools.  In  animals  I  have  found 
that  the  subcutaneous  administration  of  urea  was  followed 
at  once  by  the  appearance  of  the  salt  in  the  stomach,  while 
continued  injections  gave  rise  to  chronic  inflammation  of  the 
gastrointestinal  tract.  The  sweat  glands  also  excrete  urea 
and  likewise  undergo  inflammation  and  gradual  destruction. 

The  renal  insufficiency  that  results  from  enlargement  of 
the  prostate,  stricture  of  the  urethra,  or  obstruction  of  the 
ureters  is  accompanied  by  similar  though  less  severe  changes  in 
the  stomach  and  intestines. 

The  activity  of  the  gastric  secretion  seems  to  vary  in 
different  cases.  Van  Valzah  and  Nisbet  beheve  that  hyper- 
acidity is  common  in  the  early  stages  of  the  complaint,  and 
that  diminished  acidity  develops  subsequently.  Zipkin  found 
hyperacidity  more  common  than  anacidity,  and  Krawkow 
observed  normal  acidity  in  four,  hyperacidity  in  fourteen, 
and  anacidity  in  eight  out  of  his  twenty-six  cases.  Bier- 
nacki  studied  twenty-five  examples  of  Bright's  disease,  in- 
cluding both  the  acute  and  chronic  forms  of  the  complaint. 
From  his  observations  he  concluded  that  the  secretion  of 
gastric  juice  is  always  reduced  in  disease  of  the  kidneys,  but 
that  the  degree  of  reduction  varies  considerably  in  different 
cases.     He  also  found  that  the  amount  of  free  hydrochloric 


SYMPTOMS.  385 

acid  is  usually  reduced  in  proportion  to  the  extent  of  the 
oedema,  the  degree  of  albuminuria,  and  the  amount  of  urine 
secreted.  The  pepsin  and  rennet  ferments  are  always  dimin- 
ished in  amount  and  often  disappear  entirely.  The  motor 
power  of  the  stomach  is  usually  increased,  and  secondary  fer- 
mentations are  comparatively  rare.  In  cases  of  uraemia  the 
vomit  is  often  alkaline  in  reaction  and  may  contain  carbonate 
of  ammonium  owing  to  decomposition  of  urea  in  the  stomach. 

Symptoms. — In  the  chronic  forms  of  kidney  disease  a 
disturbance  of  digestion  is  often  the  sole  subject  of  complaint, 
and  in  the  absence  of  a  careful  examination  of  the  urine  the 
gastroenteritis  is  apt  to  be  erroneously  regarded  as  the  primary 
disorder.  The  symptoms  vary  at  first  according  to  the  na- 
ture of  the  secondary  gastritis.  Thus  in  parenchymatous  neph- 
ritis the  inflammation  of  the  tubular  glands  of  the  stomach  is 
accompanied  by  vomiting,  constipation,  and  pain  after  food, 
while  the  interstitial  gastritis  that  accompanies  the  granular 
contracted  kidney  gives  rise  to  loss  of  appetite,  nausea, 
flatulence,  emaciation,  and  an  irregular  action  of  the  bowels. 
Vomiting  in  kidney  disease,  like  that  which  results  from  other 
toxaemias,  occurs  both  in  the  early  morning  and  after  meals. 
In  the  former  case  nausea  is  experienced  as  soon  as  the 
patient  rises  from  bed,  and  after  much  retching  a  little 
alkaline  mucus  tinged  with  yellow  bile  and  mixed  with  saliva 
is  rejected.  Emesis  after  meals  may  either  occur  at  once  or 
be  postponed  for  an  hour  or  two,  and  the  ejecta  then  consist 
of  undigested  food,  mixed  with  an  excess  of  mucus,  and  almost 
devoid  of  hydrochloric  acid.  Sooner  or  later  the  stools  become 
frequent  and  loose  in  character,  and  progressive  loss  of  flesh 
occurs.  If  the  kidney  trouble  shows  signs  of  amelioration  the 
symptoms  of  dyspepsia  also  improve  for  a  time. 

The  onset  of  acute  uraemia  is  almost  invariably  marked 

by  an   access    of    vomiting  and  pain  in  the  head.     Emesis 

occurs  at  frequent  intervals,  is  excited  by  every  attempt  to 

swallow  food,  and  in  many  cases  an  extreme  degree  of  gastric 

25 


386     DISEASES    OF    THE    KIDNEYS   AND    URINARY    ORGANS. 

intolerance  is  displayed.  The  ejecta  usually  consist  of  bile- 
stained  mucus,  but  occasionally  they  are  composed  of  a  thin, 
alkaline  fluid  which  smells  strongly  of  ammonia  (Frerichs). 
In  some  instances  diarrhoea  is  the  most  prominent  symptom, 
and  the  stools  are  copious,  frequent,  and  stained  with  blood, 
while  their  evacuation  is  attended  by  griping  pain.  They  may 
possess  a  strong  odour  of  ammonia.  Lancereaux  has  drawn 
attention  to  a  peculiar  form  of  pharyngitis  that  occurs  in  cases 
of  uraemia,  and  Barie  has  observed  stomatitis  associated  with  a 
profuse  secretion  of  saliva  containing  nearly  i  per  cent,  of  urea. 
Long-continued  obstruction  to  the  passage  of  urine  from  pros- 
tatic or  other  disease  is  invariably  accompanied  by  an  extremely 
troublesome  disorder  of  digestion.  The  subjects  of  this  com- 
plaint are  usually  somewhat  emaciated  and  suffer  from  defi- 
cient circulation  in  the  hands  and  feet.  Whatever  food  they 
take  is  at  once  followed  by  fulness  and  oppression  at  the  epi- 
gastrium and  chest  and  by  excessive  flatulence.  The  appetite 
is  defective,  but  thirst  is  increased.  At  first  the  tongue  is 
slightly  furred,  but  it  gradually  becomes  dry  and  red.  The 
secretion  of  saliva  is  markedly  diminished,  and  the  buccal 
cavity  and  pharynx  present  a  glazed  appearance.  Subse- 
quently vomiting  and  diarrhoea  make  their  appearance,  and 
the  case  eventually  succumbs  either  to  exhaustion  or  to  some 
complication  of  the  urinary  disorder. 

Treatment. — Milk  should  form  the  staple  diet,  and  if 
necessary  may  be  peptonised  or  mixed  with  lime-water.  Suit- 
able aperients  must  be  administered  in  order  to  procure  a 
liquid  action  of  the  bowels  each  day,  and  for  this  purpose  a 
saline  draught  in  the  early  morning  or  a  dose  of  compound 
powder  of  jalap  is  to  be  preferred.  In  cases  where  the  secre- 
tion of  hydrochloric  acid  is  increased  a  mixture  containing 
the  carbonates  of  bismuth  and  sodium,  combined  with  glycerin 
and  carbolic  acid,  may  be  given  between  meals,  but  at  a  late 
stage  of  the  complaint  dilute  hydrochloric  acid  with  pepsin  is 
of  greater  value.     Diarrhoea  must  be  combated  by  the  ad- 


SPECIFIC   FEVERS.  387 

ministration  of  salicylate  of  bismuth,  guaiacol,  or  other  intes- 
tinal antiseptics.  If  an  urethral  stricture  exists,  it  should  be 
dealt  with  at  once;  or  if  enlargement  of  the  prostate  is  respon- 
sible for  the  retention  of  urine,  a  catheter  should  be  regularly- 
employed  or  the  gland  removed  by  operation. 

(6)  SPECIFIC  FEVERS. 

The  observations  made  by  Beaumont  were  the  first  to  in- 
dicate that  in  febrile  conditions  the  secretion  of  gastric  juice  is 
diminished  and  the  processes  of  food  digestion  greatly  re- 
tarded. Examination  of  the  gastric  contents  withdrawn  by  a 
tube  in  cases  of  fever  have  produced  somewhat  contradictory 
results,  since,  while  Ewald  noted  a  failure  of  the  secretion  of 
hydrochloric  acid,  UefEelmann  detected  an  increase,  Sazzezki, 
Edinger,  and  Gluzinski  found  that  the  quantity  varied  in 
different  cases,  and  Van  Noorden  discovered  that  he  could 
stimulate  the  production  of  the  mineral  acid  by  the  adminis- 
tration of  condiments  and  spices.  My  own  observations  seem 
to  indicate  that  the  functional  activity  of  the  stomach  in  feb- 
rile diseases  depends  chiefly  upon  its  freedom  from  inflamma- 
tion. Thus,  in  scarlatina,  which  was  shown  by  Samuel  Fen- 
wick  to  be  invariably  accompanied  by  severe  parenchymatous 
gastritis,  the  secretion  of  hydrochloric  acid  is  usually  annulled 
until  the  end  of  the  first  week,  and  a  similar  condition  is  often 
found  in  cases  of  smallpox.  In  measles  and  pneumonia, 
which  rarely  exhibit  any  organic  changes  in  the  digestive 
tract,  the  gastric  secretion  shows  little  or  no  perversion;  while 
in  enteric  fever  the  gastric  tubules  appear  quite  healthy  when 
examined  by  the  microscope,  but  the  lymphoid  tissue  of  the  mu- 
cous membrane  is  much  increased  and  occasionally  ulcerates. 
In  fatal  cases  of  pertussis  numerous  petechiae  are  found  in  the 
stomach  intermixed  with  hasmorrhagic  erosions,  and  in  certain 
cases  of  diphtheria  the  inner  surface  of  the  stomach  is  found 
to  be  covered  with  false  membrane  (Smirnhow,  Fenwick). 

Symptoms  of  dyspepsia  are  encountered  in  many  specific 


388  SPECIFIC   FEVERS. 

fevers,  and  are  particularly  pronounced  in  scarlatina  and 
smallpox,  the  onset  of  which  is  often  marked  by  severe  and 
protracted  vomiting.  Vomiting  also  accompanies  the  spread 
of  diphtheritic  membrane  to  the  stomach,  and  is  frequently 
provoked  by  the  paroxysmal  cough  of  pertussis.  In  measles, 
vomiting  and  diarrhoea  are  notable  features  of  the  crisis. 

In  all  febrile  conditions  the  secretion  of  saliva  is  diminished; 
tongue  and  mouth  become  dry  and  foul,  and  occasionally  an 
ascending  infection  of  Stenson's  duct  leads  to  suppurative 
parotitis.  The  appetite  is  always  deficient,  and  in  those  dis- 
eases that  are  accompanied  by  acute  gastritis  the  greatest 
aversion  from  food  may  exist.  A  similar  dislike  is  sometimes 
observed  in  pertussis,  but  in  this  disorder  it  can  usually  be 
traced  either  to  failure  of  the  heart  or  to  a  fear  lest  the  inges- 
tion of  food  should  excite  a  fit  of  coughing.  Severe  pain  after 
meals  is  seldom  experienced,  and  the  subjective  sensations  that 
arise  from  maldigestion  in  the  stomach  consist  for  the  most  part 
of  discomfort,  oppression  at  the  chest,  distention,  and  flatulence. 
Occasionally,  however,  the  subjects  of  influenza  suffer  from 
genuine  epigastric  pain,  and  a  similar  condition  is  sometimes 
met  with  in  pertussis  and  enteric  fever.  In  one  case  that  came 
under  my  care  fatal  haematemesis  occurred  during  the  third 
week  of  typhoid  fever  from  follicular  ulceration  of  the  stomach. 
The  signs  of  gastrectasis  are  seldom  ob'served  except  in  typhoid 
and  other  febrile  conditions  of  long  duration.  In  such  cases 
flatulence  is  often  a  conspicuous  symptom  and  both  the  stomach 
and  intestines  are  constantly  distended  with  gas.  Nausea 
and  palpitation  are  experienced  after  meals,  and  the  pressure 
of  the  distended  bowel  upon  the  bladder  gives  rise  to  a  frequent 
desire  to  micturate.  This  gastrointestinal  complaint  may 
continue  during  the  whole  period  of  convalescence  and  is  some- 
times accompanied  by  an  enlarged  and  fatty  liver.  Chronic 
dyspepsia  of  the  atonic  type  is  apt  to  follow  both  measles  and 
enteric  fever,  and  may  so  injuriously  affect  the  general  nutri- 
tion as  to  favour  the  inception  of  tubercle. 


SYPHILIS.  389 

Malaria  also  exerts  an  important  influence  upon  the  digest- 
ive system,  and  is  occasionally  responsible  for  the  develop- 
ment of  an  ulcer  of  the  stomach.  In  certain  malarious  dis- 
tricts gastralgia  is  said  to  be  exceptionally  frequent,  and  period- 
ical attacks  of  haematemesis,  curable  by  quinine,  may  accom- 
pany the  variety  known  as  pernicious  ague  (Hemmeter). 

(7)  SYPHILIS. 

Secondary  syphilis,  according  to  Fournier,  is  often  accom- 
panied by  symptoms  of  disordered  digestion,  prominent  among 
whch  are  epigastric  pain  after  meals,  loss  of  appetite,  and 
vomiting.  These  phenomena  rarely  last  for  more  than  a  week 
or  two  and  are  rapidly  cured  by  the  judicious  administra- 
tion of  mercury.  They  appear  to  arise  from  a  toxaemic 
gastritis  peculiar  to  the  disease.. 

Tertiary  syphihs  may  affect  the  stomach  in  three  ways: 
(i)  By  the  formation  of  gummata;  (2)  by  the  production  of 
endarteritis,  and  (3)  by  exciting  chronic  inflammation  of  its 
mucous  membrane. 

(i)  Gummata. — A  gumma  of  sufficient  size  to  attract  atten- 
tion is  rarely  encountered.  Chiari  observed  only  three  in- 
stances in  243  necropsies  upon  persons  suffering  from  syphilis, 
and  in  all  about  sixteen  genuine  examples  are  recorded  in  the 
literature  of  the  subject.  The  tumour,  which  is  often  multiple, 
is  usually  situated  in  the  submucous  tissue  of  the  pyloric 
region  near  the  lesser  curvature.  It  is  round  and  somewhat 
flattened  on  the  surface,  yellowish  in  colour,  firm  on  section, 
and  varies  from  3  to  7  cm.  or  more  in  diameter.  At  first  the 
mucous  membrane  which  covers  it  is  stretched  and  thin,  but, 
as  the  nodule  increases  in  size  and  its  substance  undergoes  soft- 
ening, it  usually  becomes  destroyed  and  an  ulcer  is  pro- 
duced. A  gummatous  ulcer  consequently  presents  certain 
features  which  serve  to  distinguish  it  from  the  simple  variety. 
In  shape  it  is  often  irregular,  scalloped,  or  even  triangular;  its 
edges  are  thickened  and  undermined;  while  its  walls  and  base 


390  SYPHILIS. 

are  shaggy,  cheesy,  hsemorrhagic,  or  covered  with  a  firmly 
adherent  yellow  slough.  The  mucous  membrane  in  the  vicin- 
ity of  the  neoplasm,  or  its  resultant  ulcer,  exhibits  signs  of 
chronic  inflammation  and  is  not  infrequently  studded  with 
minute  gummata.  Perforation  of  the  stomach  has  not  been 
observed,  although  in  a  case  recorded  by  Lancereaux  this 
accident  was  prevented  only  by  the  presence  of  a  cheesy 
nodule.  It  is  important  to  observe  that  in  all  these  cases 
manifestations  of  syphilis  were  present  in  the  other  abdominal 
viscera,  the  liver,  pancreas,  spleen,  or  lymphatic  glands  pre- 
senting gummata  or  cicatrices.  In  cases  of  congenital  syphilis 
in  newly  born  infants  the  small  intestine  is  particularly  apt  to 
suffer  and  small  gummata  may  often  be  found  scattered 
throughout  its  length  or  congregated  about  the  ileocaecal 
valve.  Similar  conditions  have  also  been  described  in  the 
foetus  (Bittner). 

(2)  Endarteritis. — Obliterative  endarteritis  affecting  the 
gastric  vessels  must  not  be  regarded  as  necessarily  an  indication 
of  syphilis.  It  may  be  observed  in  the  fibrous  base  of  nearly 
every  chronic  simple  ulcer,  and  in  not  a  few  cases  of  long- 
standing perigastritis  due  to  disease  of  some  neighbouring  organ. 
Its  pathology  is  similar  to  that  form  of  endarteritis  which 
commonly  accompanies  cirrhosis  of  the  lung  and  kidney,  and 
in  the  case  of  a  gastric  ulcer  its  existence  is  of  some  value  to 
the  organism,  since  the  gradual  occlusion  of  the  arteries  which 
lie  in  the  track  of  the  advancing  disease  tends  to  prevent 
haemorrhage.  Syphilitic  endarteritis,  on  the  other  hand,  is 
comparatively  rare  as  a  primary  complaint,  and,  as  far  as  my 
experience  goes,  is  always  associated  with  gummata  in  the 
liver,  spleen,  pancreas,  or  retroperitoneal  glands.  It  chiefly 
affects  the  smaller  branches  of  the  pyloric  vessels  which  ramify 
in  the  subserous  and  submucous  connective  tissue,  and  by 
diminishing  the  blood-supply  to  the  part  tends  to  induce 
inflammatory  thickening  of  the  mucous  membrane  and  to  give 
rise  to  interstitial  haemorrhages  and  superficial  ulcerations.. 


SYPHILIS.  391 

When  the  arterial  disease  is  unusually  severe  or  widely  diffused, 
the  nutrition  of  the  gastric  wall  is  so  much  reduced  that  the 
tissues  are  no  longer  capable  of  withstanding  the  solvent  action 
of  the  gastric  secretion,  which  consequently  erodes  the  surface 
and  gradually  produces  an  indolent  form  of  ulceration.  In 
other  cases  the  partially  obstructed  vessel  becomes  the  seat  of 
thrombosis,  and  the  mucous  membrane  which  it  supphes,  being 
suddenly  deprived  of  blood,  is  rapidly  digested.  In  the  former 
case  the  patient  suffers  from  the  symptoms  of  chronic  ulcer  of 
the  stomach;  in  the  latter,  from  attacks  of  acute  dyspepsia, 
which  are  not  infrequently  followed  by  hsematemesis. 

(3)  Chronic  Gastritis. — Chronic  gastritis  may  ensue  either 
as  a  direct  or  an  indirect  result  of  syphilis.  The  latter  var- 
iety is  by  far  the  more  common,  and  is  due  either  to  embar- 
rassment of  the  ga^ric  circulation  from  disease  of  the  liver  or 
spleen,  to  lardaceous  degeneration  of  the  vessels  of  the  stom- 
ach, to  secondary  disease  of  the  kidneys,  or  to  the  specific 
cachexia.  This  gastritis  does  not  differ  histologically  from  the 
ordinary  varieties,  and,  like  them,  usually  subsides  when  its  ex- 
citing cause  has  been  removed.  Chronic  inflammation  of  the 
stomach  directly  dependent  upon  the  systemic  infection  occa- 
sionally results  from  repeated  attacks  of  acute  gastritis  dur- 
ing the  early  phases  of  the  complaint,  such  as  have  been  de- 
scribed by  Jullien  and  Foumier;  but,  as  a  rule,  it  appears  only 
at  an  advanced  stage  of  the  disease,  and  is  usually  associated  with 
gummatous  lesions  of  the  bones,  liver,  or  testes.  To  the  naked 
eye  the  mucous  membrane  is  either  dull  white  and  peculiarly 
opaque,  or  appears  to  be  thickened  and  irregularly  congested, 
with  a  surface  like  velvet  pile.  On  microscopical  examination 
the  superficial  roughness  of  the  membrane  is  found  to  be  due  to 
an  absence  of  the  normal  columnar  epithelium  and  to  a  hyper- 
plasia of  the  connective  tissue  between  the  mouths  of  the  glands, 
which  give  the  section  the  appearance  of  being  covered  with 
fine  papillae.  The  capillary  vessels  which  ramify  between  the 
glands  are  dilated  and  filled  with  corpuscles;  but  here  and 


392  SYPHILIS. 

there  their  outlines  are  obscured  by  an  accumulation  of 
small  round  cells,  which  pervade  the  whole  of  the  connective 
tissue  and  form  thick  layers  around  the  mouths  and  fundi  of  the 
glands.  The  lymphoid  follicles  are  enormously  enlarged,  and 
their  cellular  elements  frequently  penetrate  the  muscularis 
mucosae  and  invade  the  submucosa.  The  gastric  glands  vary 
in  appearance  at  different  parts  of  the  section,  at  one  spot  being 
comparatively  healthy,  while  at  another  they  are  twisted, 
distorted,  or  disorganised  by  the  round-cell  infiltration.  These 
general  features  are  common  to  all  forms  of  interstitial  gastritis, 
from  whatever  cause  they  arise,  but  in  the  present  case  two 
special  phenomena  exist  which  indicate  the  syphilitic  origin 
of  the  disease.  The  first  of  these  takes  the  form  of  miliary 
granulations,  which  occupy  the  whole  thickness  of  the  mucosa 
and  may  even  invade -the  submucous  tissue  or  project  slightly 
above  the  free  surface.  These  nodules,  which  are  really 
minute  gummata,  consist  for  the  most  part  of  an  homogeneous, 
granular,  non-staining  material,  and  where  several  have 
coalesced  a  large  portion  of  the  section  may  consist  entirely 
of  this  cheesy  material.  The  other  characteristic  feature 
of  a  syphilitic  gastritis  is  a  hyperplasia  of  the  inner  coats 
of  the  small  arterioles  situated  in  the  submucosa,  which  pro- 
duces considerable  narrowing  of  their  lumina  and  not  infre- 
quently leads  to  thrombosis.  These  arterial  changes  may  be 
observed  in  any  part  of  the  section,  but  are  always  most 
noticeable  in  the  vicinity  of  the  miliary  gummata. 

Symptoms. — Chronic  ulceration  of  the  stomach  due  to 
syphilis  is  most  common  in  men  between  twenty-five  and 
forty  years  of  age,  in  many  of  whom  secondary  symptoms  of 
the  infective  disorder  were  either  very  slight  or  were  rapidly 
removed  by  treatment.  The  gastric  complaint  usually  de- 
velops slowly,  and  for  several  months  may  be  mistaken  for 
some  form  of  simple  or  inflammatory  dyspepsia;  but  sooner  or 
later  the  characteristic  symptoms  of  ulcer  manifest  themselves 
and  become  severe.     So  far  as  my  own  experience  goes,  these 


SYMPTOMS.  393 

cases  chiefly  differ  from  the  simple  variety  of  the  disease 
in  three  particulars,  the  first  of  which  is  the  extreme  severity 
of  the  pain  and  vomiting,  the  second  the  infrequency  of 
haemorrhage,  and  the  third  their  intractability  to  ordinary  treat- 
ment and  great  tendency  to  relapses. 

Pain  is  invariably  present,  and,  as  is  usual  in  gastric  ulcer, 
is  principally  experienced  in  the  epigastrium  within  half  an 
hour  after  a  meal  containing  solid  food.  In  many  instances, 
however,  the  suffering  is  almost  constant,  and  even  a  diet  of 
milk  gives  rise  to  oppression  at  the  chest  with  distention  and 
troublesome  flatulence.  When  the  disease  has  existed  for 
some  months  the  pain  is  often  most  intense  during  the  night, 
when  the  stomach  is  devoid  of  food,  and  it  may  then  extend 
all  over  the  abdomen  and  chest  and  radiate  down  the  extremi- 
ties or  up  into  the  neck.  Under  these  conditions,  the  epigas- 
trium is  usually  very  tender,  and  the  cranium,  the  tibiae,  and 
the  heels  may  also  be  unduly  sensitive  to  pressure.  The 
attacks  last  for  several  hours  and  are  frequently  accompanied 
by  flatulent  and  acid  eructations,  burning  in  the  throat,  intense 
thirst,  and  vomiting.  They  are  temporarily  relieved  by  a 
draught  of  milk  or  a  dose  of  bicarbonate  of  sodium,  and  more 
effectually  by  vomiting.  Rosanow  diagnosed  a  syphilitic  ulcer 
in  one  patient  on  account  of  the  nocturnal  pain,  and  successfully 
treated  it,  while  Bartumeus  lays  stress  upon  the  occurrence 
of  emesis  during  the  night;  but  since  both  these  phenomena 
are  met  with  in  simple  ulcer  when  complicated  with  hyper- 
secretion, they  cannot  be  regarded  as  pathognomonic  of  the 
specific  form  of  the  complaint.  Vomiting  is  another  con- 
spicuous feature  of  the  disease.  At  first  the  patient  may  be 
sick  only  during  the  painful  crises,  which  the  act  of  emesis  tends 
to  curtail;  but  as  soon  as  secondary  gastritis  develops  vomiting 
may  occur  after  every  meal,  while  from  time  to  time  attacks 
come  on  which  last  for  many  days  and  prevent  the  administra- 
tion of  nourishment  by  the  mouth.  The  constant  pain  and 
vomiting  soon  induce  a  serious  deterioration  of  the  general 


394  SYPHILIS. 

health.  The  patient  becomes  very  thin  and  feeble,  and  pre- 
sents the  pinched  and  careworn  look  of  one  who  is  always 
suffering.  The  appetite  may  remain  good  or  even  be  excessive, 
but  he  is  afraid  to  gratify  his  desire  for  food  on  account  of 
the  punishment  which  is  sure  to  follow,  while  at  intervals 
he  is  tormented  by  a  thirst  which  no  amount  of  water  will 
subdue.  The  bowels  are  confined  and  the  tongue  is  often 
covered  with  a  white  fur.  The  urine  is  diminished  in  amount 
and  its  reaction  is  often  neutral  or  slightly  alkaline,  while  in 
many  cases  it  contains  an  excess  of  phosphates  but  is  deficient 
in  chlorides.  Anaemia  is  invariably  present,  and  the  peculiar 
sallow  complexion  of  many  of  the  patients  is  very  suggestive 
of  a  specific  cachexia.  Although  nearly  70  per  cent,  of  the 
cases  of  simple  ulcer  suffer  from  hsematemesis,  this  symp- 
tom appears  to  be  comparatively  rare  in  the  syphilitic  disease, 
possibly  on  account  of  the  gradual  obliteration  of  the  gastric 
vessels,  which,  as  has  already  been  pointed  out,  occurs  in  the 
vicinity  of  the  sore.  When,  however,  the  portal  circulation 
is  embarrassed  by  coexisting  disease  of  the  liver  or  spleen, 
vomiting  of  blood  may  be  an  early  and  recurrent  symptom. 

As  a  rule,  the  complaint  fails  to  respond  to  the  ordinary 
methods  of  treatment,  and  even  when  antisyphilitic  remedies 
are  employed  it  may  exhibit  a  great  tendency  to  relapse. 

With  regard  to  the  chemistry  of  digestion  there  is  very  little 
evidence  to  offer.  In  the  early  stages  of  the  complaint  free 
hydrochloric  acid  may  usually  be  detected  after  a  test-meal,  and 
in  those  cases  where  nocturnal  attacks  of  pain  are  present  the 
vomit  usually  contains  an  excess  of  the  mineral  acid.  But 
when  the  disease  has  given  rise  to  great  loss  of  flesh  and  to 
debility  the  signs  of  hypersecretion  may  disappear  and  lactic 
acid  be  detected.  When  vomiting  is  excessive  the  ejecta  are 
often  bile-stained  and  contain  much  mucus.  The  usual  cause 
of  death  is  exhaustion  from  inanition,  but  an  intercurrent 
affection  like  tuberculosis  or  some  syphilitic  comphcation  often 
hastens  the  fatal  termination.     Hsematemesis  and  perforation 


SYMPTOMS.  395 

appear  to  be  rare.  Among  the  sequelae  of  the  disease,  pyloric 
stenosis  is  the  most  important,  and  has  been  recorded  by 
Cornil,  Wagner,  and  Klebs. 

Gastritis  occurs  both  in  hereditary  and  acquired  syphilis, 
and  is  chiefly  characterised  by  its  chronicity  and  intractability 
to  ordinary  treatment.  In  infancy  and  early  childhood  the 
intestine  usually  suffers  along  with  the  stomach,  so  that  in 
addition  to  the  vomiting  there  is  either  diarrhoea  or  obstinate 
constipation.  In  all  cases  the  loss  of  flesh,  anaemia,  and 
debility  are  out  of  proportion  to  the  severity  of  the  local  symp- 
toms, owing  to  the  consecutive  atrophy  of  the  gastric  and 
intestinal  glands,  which  can  be  demonstrated  in  almost  every 
case  of  so-caUed  "syphilitic  marasmus."  During  the  period  of 
childhood  intercurrent  attacks  of  acute  gastritis,  characterised 
by  incessant  nausea  and  vomiting  and  occasionally  by  severe 
gastralgia,  are  apt  to  occur  from  time  to  time.  The  bowels  are 
confined,  the  tongue  is  thickly  coated,  and  slight  delirium  may 
appear  at  night.  If  no  food  can  be  retained  in  the  stomach 
the  disease  may  prove  fatal;  but,  as  a  rule,  the  acute  phase 
passes  off  in  a  few  days,  and  is  replaced  by  the  chronic 
form.  In  almost  every  instance  the  child  presents  evidences  of 
syphilis  in  the  face,  teeth,  and  eyes,  while  not  infrequently  the 
development  of  a  gumma  heralds  the  onset  of  an  acute  attack. 
In  one  case  which  came  under  my  care  a  large  mass  could  be 
felt  for  several  months  in  the  liver,  and  subsequently  a  gummat- 
ous swelling  appeared  upon  the  forehead;  while  in  that  re- 
ported by  Hemmeter  the  child  presented  an  enormous  gumma 
of  the  lower  jaw. 

Mild  forms  of  syphilitic  gastritis  occurring  in  adult  life  are 
practically  indistinguishable  from  the  alcoholic  variety,  while  in 
the  more  severe  cases  the  progressive  loss  of  flesh,  excessive 
debility,  anorexia,  and  profound  anaemia,  coupled  with  an 
absence  of  free  hydrochloric  acid  from  the  gastric  contents,  are 
highly  suggestive  of  a  malignant  growth.  More  than  one  case 
of  this  description  has  come  under  my  care  in  which,  if  it  had 


396  SYPHILIS. 

not  been  for  the  routine  trial  of  iodide  of  potassium,  I  should 
have  diagnosed  cancer  of  the  stomach;  and  I  have  known 
several  patients  who  were  condemned  to  carcinoma  of  the 
stomach  or  pancreas  after  an  exploratory  incision,  who 
made  a  perfect  recovery  under  antisyphilitic  treatment. 
Although  traces  of  altered  blood  may  appear  in  the  vomit, 
severe  h£ematemesis  is  rarely  observed  unless  the  liver  or 
spleen  is  also  diseased. 

Treatment. — Absolute  rest  is  essential,  and  much  time 
will  be  saved  if  the  patient  is  confined  to  bed  for  the  first  fort- 
night. Milk  should  form  the  staple  diet  for  the  first  three  or 
four  weeks,  but  as  it  does  not  always  agree  so  well  as  in  simple 
ulcer  it  may  be  necessary  to  dilute  it  with  soda-water  or  Vichy 
water.  When  vomiting  is  a  troublesome  symptom  the  milk 
should  be  peptonised.  Clear  soups,  broths,  jellies,  and  junket 
may  also  be  allowed  if  the  patient  can  take  them  without 
discomfort.  After  the  first  month,  should  the  case  be  pro- 
gressing favourably,  milk  puddings,  soft  bread  and  butter,  eggs, 
tripe,  and  oysters  may  be  permitted,  and  the  diet  may  subse- 
quently be  increased  by  the  addition  of  pounded  fish,  finely 
minced  sweetbreads,  and  chicken-cream.  Meat  and  green 
vegetables  should  be  prohibited  for  at  least  six  months.  If 
vomiting  is  troublesome,  it  may  be  necessary  to  feed  the  patient 
by  the  rectum.  When  abdominal  pain  is  severe  the  epigastrium 
may  be  constantly  covered  with  a  large  linseed  poultice,  but, 
as  a  rule,  the  repeated  application  of  a  small  blister  is  of  greater 
value.  With  regard  to  medicinal  treatment,  it  may  be  stated 
at  once  that  mercury  should  always  be  combined  with  an  iodide, 
since  the  latter  is  much  less  efficacious  when  given  alone.  In 
most  instances  it  is  sufficient  to  prescribe  a  mercurial  pill  of 
2  grains,  with  an  equal  quantity  of  extract  of  hyoscyamus 
night  and  morning,  but  in  some  cases  drachm  doses  of  the 
solution  of  perchloride  of  mercury  are  to  be  preferred.  In 
young  children  inunctions  of  mercurial  ointment  or  full  doses 
of  mercury  and  chalk  are  the  most  convenient  methods  of  ad- 


DIABETES.  397 

ministering  the  drug.  If  there  is  any  tendency  to  diarrhoea, 
a  small  quantity  of  opium  may  be  included  in  the  prescription. 
The  iodide  of  potassium  or  sodium  must  be  given  in  doses 
of  from  5  to  15  grains,  and  is  most  conveniently  combined 
with  carbonate  of  bismuth  and  liquid  extract  of  sarsaparilla ; 
while  the  addition  of  10  minims  of  glycerin  of  carbohc  acid 
often  tends  to  relieve  the  oppression  and  flatulence  which  are 
experienced  after  meals.  Should  the  bowels  remain  consti- 
pated in  spite  of  the  mercurial,  a  teaspoonful  or  more  of  the 
artificial  Carlsbad  salts  may  be  given  each  morning  before 
breakfast.  Lavage  is  chiefly  indicated  in  the  cases  of  chronic 
gastritis  accompanied  by  troublesome  vomiting  or  where  an 
ulcer  has  caused  partial  obstruction  of  the  pylorus,  but  it 
should  be  avoided  when  symptoms  of  active  ulceration  are 
present. 

(8)  DIABETES. 

The  subjects  of  diabetes  are  liable  to  several  manifestations 
of  indigestion,  especially  during  the  later  stages  of  the  com- 
plaint. In  most  instances  discomfort  and  abdominal  disten- 
tion occur  an  hour  or  two  after  meals,  and  large  quantities  of 
gas  are  eructated  or  evacuated  by  the  bowel.  Occasionally 
acidity  is  a  prominent  symptom.  In  all  cases  the  bowels 
are  confined,  and  the  stools  are  dry,  hard,  and  often  coated 
with  mucus.  Attacks  of  subacute  gastritis  are  apt  to  super- 
vene in  debilitated  subjects,  and  are  accompanied  by  loss 
of  appetite,  increased  thirst,  pain  in  the  epigastrium,  a  furred 
tongue,  and  occasionally  by  vomiting.  Violent  abdominal 
pain  precedes  the  development  of  coma  in  many  instances, 
and  is  sometimes  brought  on  by  overexertion  and  excitement. 
It  is  usually  ascribed  to  gastralgia,  but  in  many  of  its  features 
it  closely  resembles  lead  cohc,  and  is  probably  due  to  a  tetanic 
spasm  of  the  colon  induced  by  the  toxaemia. 

A  study  of  the  physiology  of  digestion  in  these  cases  has 
brought  to  hght  one  or  two  facts  of  importance.     Rosenstein 


398  ANEMIA  AND    CHLOROSIS. 

examined  ten  diabetics  and  found  the  secretion  of  hydrochloric 
acid  to  be  normal  in  four,  while  in  six  it  was  sometimes 
normal  and  sometimes  diminished  in  quantity.  In  three 
cases  which  were  examined  after  death  chronic  interstitial 
gastritis  with  atrophy  of  the  gastric  glands  was  discovered, 
Gans  investigated  ten  cases,  and  found  that  the  composition 
of  the  gastric  juice  had  no  relation  to  the  amount  of  sugar 
eliminated.  Free  hydrochloric  acid  was  present  in  six  instances, 
but  was  absent  in  the  other  four.  In  the  eight  cases  examined 
by  Honigmann  hydrochloric  acid  was  diminished  or  absent 
in  four,  and  the  investigations  of  Rosenheim,  See,  and  Krause 
have  afforded  somewhat  similar  results.  Both  Honigmann 
and  Gans  noted  that  the  motor  power  of  the  stomach  was 
perfectly  normal  in  cases  of  diabetes.  In  some  of  my  cases 
the  gastric  contents  contained  a  large  percentage  of  sugar, 
and  the  administration  of  yeast  by  the  mouth  produced  ex- 
cessive distention  and  flatulence.  It  is,  therefore,  probable 
that  the  diminished  secretion  of  hydrochloric  acid,  which  is 
so  often  met  with,  encourages  the  fermentation  of  the  saccharine 
fluid  excreted  by  the  gastric  mucous  membrane,  and  thus 
produces  the  distention  and  other  symptoms  of  diabetic 
dyspepsia.  Subsequently  the  products  of  fermentation  excite 
a  chronic  interstitial  gastritis,  which,  if  it  terminates  in  ex- 
tensive atrophy  of  the  peptic  glands,  produces  that  failure 
of  the  gastric  secretion  and  cachexia  which  sometimes  manifest 
themselves  in  the  last  stage  of  the  disease. 

(9)  AN.EMIA  AND   CHLOROSIS. 

These  two  conditions  must  be  carefully  distinguished  from 
one  another.  Ancemia  is  characterised  by  a  deficiency  of 
red  corpuscles,  with  perhaps  an  increase  of  the  white  cells, 
and  is  caused  by  direct  loss  of  blood,  haemolysis,  or  by  some 
other  affection  which  reduces  the  quantity  of  blood  in  the  cir- 
culation. In  chlorosis,  on  the  other  hand,  the  haemoglobin  is 
chiefly  diminished,  and  the  blood  corpuscles  show  compara- 


ANEMIA  AND    CHLOROSIS.  399 

tively  little  change.  When  these  primary  distinctions  are  borne 
in  mind,  it  is  not  surprising  to  find  that  the  two  complaints 
are  commonly  accompanied  by  different  disorders  of  digestion. 

Ancemia. — Animals  suffering  from  the  effects  of  vene- 
section were  found  by  Korczinski  and  Jaworski  to  exhibit  a 
deficient  secretion  of  hydrochloric  acid,  and  Manassein  ob- 
tained similar  results  from  his  experiments  on  dogs.  The 
observations  of  Buzclygan  and  Gluzinski  upon  the  subjects 
of  severe  haemorrhage  were  somewhat  contradictory  in 
character,  but  they  seemed  to  demonstrate  a  uniform  ab- 
sence of  hydrochloric  acid  in  persons  affected  with  malarial 
cachexia.  Pineau  and  others  have  noted  the  existence  of 
achylia  in  pernicious  anaemia.  The  type  of  dyspepsia  which 
accompanies  anaemia  varies  according  to  the  cause  of  the  blood 
disorder.  Thus,  when  the  anaemia  is  due  to  kidney  disease, 
phthisis,  or  malaria,  a  secondary  gastroenteritis  occurs,  which 
is  responsible  for  vomiting  and  diarrhoea;  in  pernicious  anaemia 
atrophy  of  the  stomach  gives  rise  to  severe  attacks  of  emesis,  flat- 
ulence, and  anorexia;  in  the  cachexia  of  syphihs  the  diminished 
blood  supply  of  the  gastric  mucous  membrane  often  produces 
symptoms  of  ulceration,  while  after  a  severe  loss  of  blood  the 
resultant  indigestion  exhibits  the  general  characters  of  that 
which  ensues  from  subacidity. 

Chlorosis. — In  this  disorder  the  secretion  of  hydrochloric 
acid  is  more  often  increased  than  diminished.  It  is  true  that 
Ritter  and  Hirsch  found  the  gastric  juice  deficient  in  several 
cases,  while  Schneider  noted  anacidity  in  54.2  per  cent,  of 
those  which  he  examined,  but  the  more  recent  enquiries  of 
Griine,  Osswald,  Hayem,  and  Schatzell  throw  considerable 
doubt  upon  the  accuracy  of  these  earlier  observations. 

Thus,  in  the  seventy-two  cases  examined  by  Hayem  the 
amount  of  hydrochloric  acid  was  found  to  be  normal  in  two, 
excessive  in  forty-two,  and  diminished  in  twenty-eight; 
Schatzell  detected  hyperacidity  in  twenty-two  out  of  his  thirty 
cases,  and  Riegel  states  that  in  the  majority  of  the  chlorotics 


400  NERVOUS    DISEASES. 

under  his  care  the  mineral  acid  was  in  excess.  The  motor 
power  of  the  stomach  both  in  anaemia  and  chlorosis  rarely 
suffers  deterioration  whatever  be  the  state  of  the  gastric 
secretion  (Riegel). 

Four  principal  forms  of  indigestion  are  met  with  in  subjects 
of  chlorosis.  Most  frequently  the  chief  causes  of  complaint 
are  distention  and  flatulence  after  meals,  which  arise  from 
fermentation  of  the  food  and  a  deficient  action  of  the  bowels 
(Chap.  III).  In  other  cases  severe  pain  is  experienced  im- 
mediately after  food,  vomiting  is  of  frequent  occurrence,  and 
the  entire  region  of  the  stomach  is  tender  on  pressure.  This 
disorder  is  due  to  hyperaesthesia  of  the  gastric  mucous  membrane 
and  is  readily  cured  by  the  administration  of  iron  and  suitable 
aperients  (Chap.  V).  Less  often  the  symptoms  of  hyper- 
acidity manifest  themselves,  and  careful  dieting  is  required  to 
cure  the  complaint  (Chap.  II),  while  occasionally  the  gastric 
symptoms  are  dependent  upon  gastroptosis,  accompanied, 
perhaps,  by  some  perversion  of  secretion  (Chap.  VI). 

(lo)  NERVOUS  DISEASES. 

Most  organic  diseases  of  the  brain,  especially  tumour, 
basic  meningitis,  haemorrhage,  and  abscess,  are  accompanied 
by  vomiting.  This  symptom  is  purely  central  in  origin  and 
is  not  associated  with  any  demonstrable  lesion  of  the  stomach. 
The  emesis  itself  exhibits  no  constant  relation  to  the  quantity 
or  quality  of  the  food,  and  often  occurs  when  the  stomach 
is  empty,  in  which  case  severe  retching  merely  relieves  the 
organ  of  a  little  bile  or  mucus.  In  certain  cases  of  cerebral 
tumour,  attacks  of  vomiting  occur  at  intervals  and  are  preceded 
by  severe  headache,  while  the  vomited  material  consists  almost 
entirely  of  gastric  juice  mixed  with  bile  and  containing  an  ex- 
cess of  free  hydrochloric  acid.  These  phenomena  are  closely 
allied  to  those  of  acute  hyperscretion  and  unless  the  optic 
discs  be  examined  in  every  case  which  displays  symptoms  of 
this  nature  a  serious  error  in  diagnosis  may  be  committed. 


PREGNANCY.  4OI 

Certain  affections  of  the  spinal  cord  are  also  accompanied 
by  gastric  symptoms,  prominent  among  which  is  locomotor 
ataxia  with  its  well-known  crises.  Sahli  and  others  have  re- 
ported the  existence  of  hypersecretion  in  such  cases,  but,  as  a 
rule,  neither  hyperacidity  nor  continuous  secretion  can  be 
detected. 

Certain  psychoses  are  attended  by  an  alteration  of  the 
gastric  secretion.  Thus,  v.  Noorden  found  hyperacidity  fre- 
quent in  melancholia  and  that  the  period  of  gastric  digestion 
was  much  curtailed;  while  in  dementia,  Leubuscher  and 
Ziehen  observed  a  marked  diminution  of  gastric  activity. 
Hysteria  gives  rise  to  many  secondary  affections  of  the  di- 
gestive organs,  of  which  hyperassthesia,  anorexia,  and  hys- 
terical vomiting  are  the  most  important.  In  the  latter  con- 
dition emesis  usually  takes  place  regularly  after  meals  but 
does  not  destroy  the  appetite.  It  is  also  to  be  noticed  that 
although  vomiting  is  usually  said  to  be  excessive  the  patients 
never  lose  weight,  from  which  fact  it  may  be  inferred  that 
only  a  small  portion  of  the  contents  of  the  stomach  are  re- 
jected on  each  occasion.  The  chief  effect  of  neurasthenia 
upon  the  digestive  organs  has  already  been  described  under 
the  title  of  neurasthenia  gastrica  (Chap.  V). 

(II)  PREGNANCY. 

Although  pregnancy  cannot  be  regarded  as  a  morbid 
condition  in  the  strict  sense  of  the  word,  its  effects  upon  the 
digestive  system  are  of  sufficient  importance  to  merit  a  more 
detailed  description  than  is  usually  accorded  to  them  by  writers 
upon  disorders  of  the  stomach.  In  most  obstetrical  works  the 
dyspepsia  of  pregnancy  is  regarded  as  synonymous  with  "vom- 
iting," and  the  causation  and  treatment  of  this  symptom 
are  alone  discussed.  It  must  be  obvious,  however,  to  every 
clinician  that  sickness  is  by  no  means  the  only  indication  of 
dyspepsia  occurring  in  pregnancy  and  that  the  cases  which 
suffer  from  vomiting  are  often  in  a  much  happier  condition 
26 


402  PREGNANCY. 

than  those  who  have  to  endure  the  less  obtrusive  but  more 
uncomfortable  phenomena  associated  with  indigestion.  There 
are  three  varieties,  or  "degrees,"  of  digestive  disturbance  which 
require  notice,  namely,  flatulent  distention,  occasional  vomit- 
ing, and  gastric  intolerance  or  "pernicious  vomiting." 

(i)  Excessive  flatulence  is  chiefly  encountered  in  women 
who  never  vomit.  It  usually  commences  about  the  sixth 
week  and  continues  until  the  end  of  the  eighth  month.  It  is 
most  frequent  in  neurotic  and  hysterical  individuals  and  in  those 
who  have  long  suffered  from  some  functional  disturbance  of 
the  digestion.  It  is  also  extremely  common  in  the  subjects  of 
gastroptosis.  As  a  rule,  it  takes  the  form  of  acute  attacks, 
which  recur  every  week  or  ten  days  and  last  from  twenty-four 
to  forty-eight  hours,  but  occasionally  the  sense  of  abnormal 
distention  is  continuous  and  merely  varies  in  degree. 

An  attack  is  ushered  in  by  malaise,  want  of  appetite,  and 
oppression  at  the  chest  after  food.  At  first  the  epigastric 
region  is  the  chief  seat  of  discomfort,  but  very  soon  the  whole 
of  the  abdomen  becomes  distended,  tense,  and  extremely 
tender.  Nausea,  giddiness,  and  palpitation  soon  develop,  and 
the  head  may  seem  to  be  overfilled  with  blood.  Within  a 
short  time  belching  of  an  odourless  gas  supervenes,  but  this 
only  gives  temporary  relief  and  does  not  appear  to  diminish 
the  gastric  and  intestinal  distention.  In  other  instances  the 
constant  passage  of  flatus  is  a  troublesome  symptom.  The 
patient  is  unable  to  lie  down  owing  to  abdominal  discom- 
fort, and  there  is  often  an  incessant  desire  to  pass  water.  The 
bowels  are  always  confined.  The  attack  is  followed  by  prostra- 
tion and  a  feeling  of  soreness  of  the  abdomen.  The  disorder 
differs  from  nervous  eructation  (Chap.  V)  in  that  the  signs  of 
flatulent  distention  of  the  stomach  and  bowels  are  very  con- 
spicuous, while  immense  quantities  of  gas  are  eructated  or 
evacuated  by  the  rectum.  If  the  woman  is  the  subject  of 
valvular  disease  of  the  heart,  severe  and  even  dangerous  syn- 
cope may  occur,  but,  as  a  rule,  recovery  ensues  as  soon  as  the 


PREGNANCY.  403 

distention  abates.     It  is  worthy  of  notice  that  fatigue,  excite- 
ment, or  a  mental  shock  will  invariably  induce  an  attack. 

(2)  Vomiting  occurs  in  about  80  per  cent,  of  all  cases  of 
pregnancy,  and  is  especially  common  in  the  primipara.  It 
usually  commences  about  the  sixth  week  and  continues  until 
the  eighteenth  or  twentieth,  but  it  may  be  experienced  at  inter- 
vals until  the  commencement  of  the  ninth  month.  It  is 
rarely  observed  during  the  first  and  last  months  of  pregnancy. 

In  most  instances  it  takes  the  form  of  severe  retching  in  the 
early  morning  when  the  patient  arises  from  bed,  which  results 
in  the  expulsion  of  a  httle  gas  from  the  stomach,  but  in  other 
instances  there  is  much  antecedent  nausea  and  the  ejecta  con- 
sist of  thick  mucus  mixed  with  saliva  and  bile.  This  form 
of  vomiting  is  therefore  very  similar  to  that  met  with  in  the 
various  forms  of  toxic  gastritis,  and  is  distinguished  from  that 
of  early  phthisis  by  the  absence  of  cough.  When  vomiting 
occurs  after  meals,  nausea  develops  as  soon  as  food  has 
been  swallowed,  and  the  patient  is  obliged  to  leave  the  table 
in  order  to  vomit.  In  other  instances  the  attack  is  deferred 
until  after  the  meal,  and  is  then  preceded  by  much  nausea, 
palpitation,  and  salivation.  As  far  as  my  experience  goes, 
the  vomit  consists  of  undigested  food  and  contains  no  free 
acid,  but  Fox  and  a  few  other  writers  about  the  middle  of 
last  century  speak  of  the  existence  of  "hypersecretion."  In 
all  cases  the  bowels  are  confined,  and  the  appetite  is  capricious. 
Occasionally,  the  vomiting  appears  to  arise  from  some  violent 
emotion,  or  is  induced  by  the  smell  of  fish,  game,  or  lilies, 
by  a  hot  atmosphere,  or  by  the  movement  of  a  vehicle. 

(3)  Gastric  intolerance,  or  pernicious  vomiting,  is  a  rare  but 
very  dangerous  gastric  disorder  of  pregnancy.  Like  the 
former  variety,  it  may  commence  at  any  period  after  the  first 
month  and  continue  until  the  seventh  or  eighth  month.  As  a 
rule,  however,  serious  exhaustion  develops  between  the  third 
and  the  fifth  months,  to  which  the  patient  either  succumbs 
or  from  which  she  is  saved  by  the  induction  of  abortion. 


404  PREGNANCY. 

In  this  variety  nausea  and  retching  occur  at  all  times  of  the  day 
and  every  attempt  to  administer  nourishment  by  the  mouth 
at  once  excites  vomiting.  This  condition  of  gastric  intolerance 
produces  such  rapid  emaciation  and  profound  weakness  that 
syncope  is  apt  to  occur  after  the  least  exertion.  The  bowels 
are  confined,  the  urinary  secretion  is  scanty,  and  the  skin 
becomes  dry  and  harsh.  With  the  progress  of  the  complaint 
the  pulse  increases  in  rapidity,  the  tongue  grows  foul,  delirium 
accompanied  by  intermittent  fever  supervenes,  and  icterus 
often  makes  its  appearance  before  death. 

Etiology. — It  has  always  been  the  custom  to  ascribe  the 
"vomiting"  of  pregnancy  to  nervous  or  reflex  causes.  In 
the  former  category  hysteria  is  supposed  to  play  the  predomi- 
nant role,  while  in  the  latter  stretching  of  the  uterine  nerves, 
pressure  of  the  enlarged  organ  upon  those  of  the  sacral  plexus, 
congestive  inflammation  of  the  os  or  cervix,  inflammation 
of  the  deciduae,  or  displacement  of  the  uterus  are  regarded  as 
the  most  important.  When,  however,  the  disorder  is  consid- 
ered in  the  light  of  our  present  knowledge  of  diseases  of  the 
digestive  organs,  there  are  several  facts  which  militate  greatly 
against  the  theories  of  nervous  origin.  In  the  first  place,  there 
is  no  reason  to  regard  the  gastric  intolerance  of  pregnancy  as 
a  clinical  entity,  since  its  symptoms  are  exactly  similar  to  those 
met  with  in  toxic  inflammations  of  the  stomach.  On  the 
other  hand,  it  differs  widely  from  those  forms  of  vomiting 
which  ensue  from  cerebral  or  spinal  irritation,  as  well  as  from 
the  secondary  forms  of  hypersecretion  which  are  produced 
in  a  reflex  manner.  Secondly,  the  jaundice  and  fever  which 
sometimes  accompany  the  complaint,  although  common  in 
cases  of  toxic  gastritis,  are  never  met  with  in  disorders  of 
digestion  of  nervous  origin.  Thirdly,  vomiting  in  the  early 
morning  is  a  very  characteristic  symptom,  and  when  it  appears 
independently  of  cough,  invariably  indicates  the  existence  of 
chronic  gastritis.  Fourthly,  no  theory  of  reflex  irritation  will 
explain  the  dyspepsia  which  occurs  in  pregnant  women  who  do 


TREATMENT.  405 

not  vomit,  the  features  of  which,  however,  are  identical  with 
those  that  ensue  from  certain  toxic  inflammations  of  the 
stomach  and  intestine.  Finally,  although  the  stomach  may- 
present  to  the  naked  eye  no  indications  of  inflammation  after 
death,  I  have  never  known  a  case  of  fatal  vomiting  in  pregnancy 
in  which  the  microscope  failed  to  demonstrate  severe  parenchy- 
matous gastritis,  and  a  similar  statement  was  made  by  Wilson 
Fox  about  the  middle  of  last  century. 

These  facts  appear  to  negative  the  hypothesis  of  simple 
nervous  or  reflex  irritation,  and  to  indicate  that  in  all  probability 
the  digestive  disturbances  of  pregnancy  are  dependent  upon 
absorption  from  the  uterus  of  some  toxic  substance  which  is  ex- 
creted by  the  stomach  and  bowel  after  the  manner  of  urea  and 
other  products  of  metabolism.  Idiosyncrasy  plays  such  an  im- 
portant part  in  the  influence  of  poisons  upon  the  organs  of  the 
body,  that,  granted  a  condition  of  toxic  absorption  from  the 
uterus,  it  might  reasonably  be  concluded  that  the  same  dose 
would  affect  some  women  more  than  others;  while  the  accidental 
existence  of  an  abnormally  high  intrauterine  pressure  would  of 
necessity  promote  a  more  rapid  absorption  of  the  poison.  This 
theory  of  increased  pressure  would  account  for  the  relief  of  the 
gastric  symptoms  which  sometimes  ensues  from  digital  dilata- 
tion of  the  cervix,  as  well  as  for  the  rapid  disappearance  of 
the  vomiting  which  commonly  occurs  after  rupture  of  the 
membranes,  even  though  delivery  is  postponed  for  several  days. 

Treatment. — There  are  three  great  indications  for  the 
treatment  of  the  dyspepsia  of  pregnancy :  exercise,  aperients,  and 
the  administration  of  hydrochloric  acid.  The  patient  should 
be  made  to  take  a  good  walk  each  day,  and  should  continue 
to  do  so  throughout  the  whole  period  of  her  pregnancy.  Aperi- 
ents are  always  necessary,  whether  the  bowels  appear  to  act 
spontaneously  or  not,  and  for  this  purpose  2  grains  or  more 
of  the  extract  of  cascara  sagrada  or  of  grey  powder  may  be 
taken  each  evening,  or  a  pill  containing  creasote,  podophyllin, 
and  rhubarb  may  be  prescribed.     The  dose  of  the  aperient 


4o6  PREGNANCY. 

should  be  gradually  increased  as  the  pregnancy  progresses. 
With  regard  to  medicinal  treatment,  nothing  exerts  such  a 
beneficial  effect  as  dilute  hydrochloric  acid,  in  doses  of  15 
drops  after  each  meal.  Vomiting  in  the  early  morning  is  an 
effort  on  the  part  of  nature  to  get  rid  of  the  sticky  mucus  that 
has  collected  in  the  stomach  during  the  night,  and  in  this 
respect  resembles  the  cough  that  occurs  in  early  phthisis.  It 
is  best  treated  by  the  administration  of  a  dessertspoonful  of 
phosphate  of  sodium  or  of  Rochelle  salt  in  a  tumblerful  of  hot 
water  one  hour  before  rising  from  bed.  The  sickness  that 
ensues  after  meals  can  almost  always  be  controlled  by  a  dose 
of  hydrochloric  acid  and  compound  infusion  of  gentian,  either 
alone  or  combined  with  20  grains  of  peptenzyme  or  5  grains 
of  pepsin.  In  these  cases  also  a  saline  in  the  early  morning  is 
usually  beneficial.  In  the  less  severe  cases  of  gastric  intolerance 
small  doses  of  peptonised  milk  or  koumiss  should  be  adminis- 
tered every  hour,  while  in  more  severe  instances  recourse 
must  be  had  to  rectal  feeding,  15  oz.  to  a  pint  of  peptonised 
milk  being  slowly  run  into  the  bowel  through  a  catheter  every 
six  hours. 

Lavage  with  a  warm  alkaline  water  is  one  of  the  most 
effective  methods  of  controlhng  the  excessive  emesis,  the  stom- 
ach being  well  washed  out  two  or  three  times  a  day.  After  a 
few  days  6  oz.  of  warm  peptonised  milk  will  often  be 
retained  if  introduced  into  the  viscus  under  pressure  through 
a  tube  (gavage).  Since  general  exhaustion  always  tends  to 
maintain  the  emesis,  much  good  may  be  done  by  large 
saline  transfusions  into  the  cellular  tissue  of  the  pectoral  region. 
Among  the  numerous  drugs  that  have  been  recommended  for 
the  treatment  of  pernicious  vomiting  the  hypodermic  adminis- 
tration of  morphine  and  atropine,  full  doses  of  chloretone  by 
the  mouth,  or  of  bromides  by  the  bowel  are  probably  the  most 
valuable.  Rapid  emaciation  accompanied  by  a  dry  tongue, 
rapid  pulse,  and  delirium  are  indications  for  the  induction  of 
abortion. 


DYSPEPSIA   DUE    TO   DRUGS.  407 

(12)  DYSPEPSIA  DUE  TO  DRUGS. 

Comparatively  little  is  known  respecting  the  toxic  influence 
of  drugs  upon  the  digestive  organs.  Chronic  poisoning  by 
phosphorus,  arsenic,  antimony,  and  alcohol  is  usually  accom- 
panied by  chronic  inflammation  of  the  stomach  and  intestines, 
with  fatty  degeneration  of  the  cells  of  the  gastric  glands  and  of 
Lieberkiihn's  follicles,  and  by  organic  changes  in  the  liver  and 
kidneys.  Digitahs,  trinitrine,  and  the  sahcylates  and  iodides  are 
also  apt  to  excite  gastritis,  while  in  some  persons  even  small 
doses  of  iron,  quinine,  and  nux  vomica  invariably  produce  a 
similar  disorder.  It  is  probable  that  many  metallic  salts  are 
absorbed  by  the  intestine  and  subsequently  excreted  by  the 
peptic  glands  which  fall  victims  to  their  own  abnormal  activity. 
Thus,  in  frogs  and  guinea-pigs  I  found  that  the  injection  of 
sulphate  of  iron  beneath  the  skin  was  soon  followed  by  the 
appearance  of  the  salt  in  the  contents  of  the  stomach,  while 
repeated  injections  gave  rise  to  acute  gastritis,  the  micro- 
scopical signs  of  which  were  accompanied  by  the  presence  of 
iron  in  the  peptic  cells.  When  a  tendency  to  hyperacidity  ex- 
ists all  tonic  remedies  excite  an  excessive  secretion  of  hydro- 
chloric acid.  Hitzig's  experiments  with  morphine  show  that 
when  the  drug  is  injected  subcutaneously,  a  considerable  pro- 
portion of  the  salt  is  excreted  by  the  stomach  and  gives  rise  to 
a  marked  diminution  of  the  gastric  secretion.  In  morphinism 
the  production  of  hydrochloric  acid  is  practically  suspended, 
but  if  the  patient  is  successfully  treated  this  secretion  becomes 
gradually  re-established. 


CHAPTER  X. 
INTESTINAL   INDIGESTION. 

The  problem  of  indigestion  in  the  intestines  is  an  exceed- 
ingly complex  one.  In  the  case  of  the  stomach,  the  develop- 
ment of  discomfort  within  two  hours  of  a  meal,  combined 
with  nausea,  vomiting,  or  gaseous  eructation,  always  indicates 
that  organ  as  the  seat  of  the  disorder,  while  the  adoption  of 
clinical  methods  which  permit  an  accurate  estimation  to  be 
made  of  the  secretory  and  motorial  powers  of  the  viscus  help 
to  establish  an  accurate  diagnosis.  The  intestine,  however, 
differs  from  the  stomach  in  several  important  particulars.  The 
canal  itself  is  relatively  inaccessible,  and  although  duodenal 
intubation  may  in  the  future  become  an  established  factor  in 
diagnosis,  its  performance  can  never  be  so  easy  nor  its  results  so 
unequivocal  as  exploration  of  the  stomach.  An  examination  of 
the  excreta,  again,  is  a  difl&cult  and  laborious  procedure,  which 
a  busy  practitioner  has  neither  the  special  knowledge  nor  yet 
the  time  to  pursue,  while  the  results  obtained  from  it,  although 
affording  valuable  information  concerning  the  digestion  and 
absorption  of  the  various  food-stuffs,  are  liable  to  be  perverted 
by  so  many  accidental  factors,  that  it  is  doubtful  whether  it 
will  ever  serve  to  demonstrate  with  certainty  the  disease  from 
which  the  aberration  of  function  arises.  The  intestinal  canal 
is  also  the  recipient  of  at  least  three  secretions,  each  of  which 
combines  several  separate  functions  whose  energy  may  be 
temporarily  increased  or  diminished  through  the  influence  of 
local  conditions,  the  existence  of  which  can  neither  be  foretold 
nor  even  recognised  with  certainty. 

Again,  the  numerous  bacteria  that  inhabit  the  alimentary 
tract  possess  important  putrefactive  properties,  the  activity 

408 


NORMAL   AND  ABNORMAL   DIGESTION.  409 

of  which  is  vastly  increased  in  all  disorders  of  the  digestive 
and  excretory  organs  of  the  body.  Finally,  there  is  always  a 
close  resemblance  between  the  general  symptoms  of  gastric 
and  intestinal  indigestion,  and  when  a  painful  contraction  of 
the  colon  ensues  immediately  after  the  ingestion  of  food, 
much  difficulty  may  exist  in  assigning  the  pain  to  its  proper 
cause,  especially  if  the  stomach  happens  to  He  abnormally  low 
in  the  abdominal  cavity.  For  these  several  reasons  it  is 
advisable  to  consider,  in  the  first  place,  the  general  effects  of  a 
disturbance  of  the  intestinal  functions  and  subsequently  the 
nature  and  symptoms  of  such  morbid  conditions  as  may  be 
regarded  as  clinical  entities. 

Normal  and  Abnormal  Digestion. — The  first  portion 
of  the  intestinal  canal,  or  duodenum,  is  probably  one  of  the 
most  important  regions  of  the  whole  tract.  Although  only 
about  10  inches  in  length,  it  receives  the  entire  secretions  of 
the  liver  and  pancreas,  besides  producing  by  means  of  its 
own  glands  a  distinct  and  important  juice.  In  shapfe  it  is 
very  like  a  horseshoe,  and  this  curious  contour  is  permanently 
preserved  by  its  fixation  to  the  spine  and  contiguous  tissues. 
Viewed  from  the  front,  with  the  stomach  and  jejunum  attached, 
it  exhibits  a  great  similarity  to  the  trap  of  a  water-closet,  and, 
from  the  fact  that  it  usually  contains  fluid,  there  can  be  no 
doubt  that  one  of  its  functions  is  to  prevent  regurgitation  of 
gas  and  chyme  from  the  lower  regions  of  the  bowel.  Its  location 
is,  however,  one  of  considerable  danger,  since  it  encircles  the 
head  of  the  pancreas,  which  is  liable  to  chronic  if  not  to  tem- 
porary enlargements,  while  its  third  portion  is  sandwiched 
between  the  abdominal  aorta  and  the  superior  mesenteric 
artery,  both  of  which  are  prone  to  extreme  degrees  of  atheroma 
as  well  as  to  aneurismal  dilatation.  The  duodenum  is  also 
the  first  part  of  the  intestine  to  feel  the  effects  of  disordered 
gastric  digestion  and  to  be  exposed  to  any  irritant  poison 
introduced  through  the  mouth  or  eliminated  by  the  bile; 
while  its  special  glands  act  vicariously  as  kidneys  in  the  ex- 


4IO  INTESTINAL   INDIGESTION. 

cretion  of  organic  poisons  from  the  circulation.  It  is  small 
wonder,  therefore,  that  the  duodenum  is  more  liable  to  in- 
flammation than  any  other  portion  of  the  intestine  and  that 
this  complaint  is  attended  by  a  disturbance  not  only  of  its 
own  secretion,  but  also  of  the  functions  of  the  other  important 
organs  of  digestion.  It  has  already  been  mentioned  that  the 
duodenum  usually  contains  a  certain  amount  of  fluid  in  its 
dependent  loop.  This  is  due  to  the  automatic  preparations 
that  are  constantly  in  evidence  in  this  portion  of  the  bowel 
for  dealing  immediately  with  the  chyme  transmitted  from  the 
stomach,  both  in  the  interests  of  digestion  and  also  as  a  safe- 
guard against  injury  by  any  sudden  increase  of  the  gastric 
acidity.  In  the  intervals  of  digestion,  such  as  normally  occur 
during  the  early  hours  of  the  morning,  the  secretions  of  the 
liver  and  pancreas  remain  stored  within  the  ducts  of  their 
respective  glands;  but  as  soon  as  food  enters- the  stomach  these 
juices  are  poured  into  the  bowel  where  they  become  mixed 
with  the  succus  entericus.  The  amount  of  this  "preparatory" 
secretion,  as  well  as  its  degree  of  alkalinity,  are  directly  propor- 
tionate to  the  nature  of  the  meal  and  the  acidity  of  the  gastric 
juice;  and  although  it  usually  ceases  as  soon  at  the  last  rem- 
nants of  chyme  have  passed  into  the  jejunum,  it  is  probably 
continuous  in  cases  of  gastric  hypersecretion  and  in  those 
where  pyloric  spasm  causes  prolonged  retention  of  food  in  the 
stomach.  While  awaiting  the  advent  of  chyme  the  duodenum 
is  motionless;  but  as  soon  as  the  gastric  contents  commence  to 
pass  through  the  pylorus  an  energetic  peristalsis  is  set  up,  which 
serves  to  effect  a  rapid  incorporation  of  the  chyme  with  the 
preparatory  secretion  and  to  hurry  the  mixture  into  the  lower 
regions  of  the  bowel  where  the  ultimate  processes  of  digestion 
and  absorption  take  place.  The  first  portions  of  the  gastric 
chyme  rarely  contain  free  hydrochloric  acid,  and  consequently 
the  material  in  the  duodenum  remains  alkaline  for  some  time; 
but  with  each  fresh  consignment  neutralisation  becomes  less 
complete    until    eventually   the    duodenal    contents    remain 


NORMAL   AND   ABNORMAL   DIGESTION.  411 

permanently  acid.  A  slight  degree  of  free  acidity  does  not 
interfere  with  intestinal  digestion  while  it  probably  stimulates 
both  the  secretion  of  the  pancreas  and  the  peristalsis  of 
the  upper  bowel,  with  the  result  that  the  alkahnity  of  the 
former  becomes  progressively  augmented  and  the  chyme  is 
expelled  with  greater  celerity  into  the  jejunum.  It  is  only 
when  a  permanent  excess  of  free  hydrochloric  acid  occurs  in 
the  duodenum  that  the  processes  of  intestinal  digestion 
become  seriously  disturbed.  If  it  were  not  for  the  provision 
of  the  "preparatory  secretion,"  which  always  awaits  the  advent 
of  the  chyme,  not  only  would  digestion  in  the  intestines  be 
suspended  until  sufficient  secretion  had  been  poured  out  to 
deal  with  the  various  food-stuffs,  but  the  organism  would  be 
exposed  during  the  interval  to  all  the  dangers  that  ensue  from 
the  continued  existence  of  free  hydrochloric  acid  in  the  upper 
bowel.  The  time  occupied  by  the  transit  of  chyme  through 
the  duodenum  is  too  brief  to  permit  of  much  digestion  or  ab- 
sorption in  this  portion  of  intestine,  and  the  term  "duodenal 
digestion"  must  therefore  be  regarded  as  a  misnomer.  In 
like  manner  "duodenal  indigestion"  cannot  be  considered  as  a 
clinical  entity,  since  the  phenomena  that  are  attributed  to  it 
are  really  produced  in  the  jejunum  and  ileum  and  are  dependent 
either  upon  an  abnormal  condition  of  the  pancreatic  or  biliary 
secretions  or  upon  disease  of  the  intestinal  mucous  membrane. 
The  part  played  by  the  bile  in  the  chemical  elaboration 
of  the  food  is  a  subject  that  has  been  much  debated,  but  there 
is  little  doubt  that  were  it  not  of  considerable  importance  in 
the  scheme  of  digestion  it  would  not  be  poured  into  the  in- 
testine so  close  to  the  stomach  and  along  with  the  potent 
secretion  of  the  pancreas,  nor  would  it  vary  so  markedly  in 
quantity  with  different  kinds  of  food.  Among  other  properties, 
bile  promotes  a  partial  emulsification  of  fats  and  also  aids 
the  fat-splitting  ferment  of  the  pancreas,  it  having  been  shown 
by  V.  Nencki  that  a  mixture  of  bile  and  pancreatic  juice 
splits  up  nearly  three  times  as  much  fat  as  can  be  effected  by 


412  INTESTINAL   INDIGESTION. 

the  latter  fluid  alone.  By  its  alkalinity  bile  increases  the 
formation  of  soaps,  and  it  also  facilitates  their  absorption  by 
the  intestinal  mucous  membrane.  It  also  stimulates  the 
peristaltic  movements  of  the  bowel.  The  fatty  stools,  con- 
stipation and  the  excessive  intestinal  putrefaction  which  ac- 
company chronic  jaundice  amply  confirm  the  existence  of 
these  physiological  functions  of  the  hepatic  secretion.  Several 
by-products  of  digestion  as  well  as  many  substances  that 
accidentally  gain  access  to  the  body  are  eliminated  by  the 
liver  and  are  thereby  rendered  innocuous  to  the  system,  although 
in  some  instances  the  mere  contact  of  this  toxic  bile  with  the 
surface  of  the  duodenum  appears  to  excite  severe  inflammation 
of  its  mucous  membrane.  Bile  is  never  absorbed  into  the 
circulation  through  the  blood  capillaries,  but  invariably  finds 
its  way  into  the  lymphatics  of  the  liver  and  thence  into  the 
blood  through  the  thoracic  duct.  The  patency  of  the  latter 
is  consequently  essential  to  the  production  of  jaundice  in 
cases  of  obstruction  of  the  common  bile-duct. 

The  pancreatic  juice  is  also  a  continuous  secretion  which 
remains  stored  up  in  the  ducts  of  the  gland  until  required  for 
use.  It  is  thick,  transparent,  and  colourless,  and  is  strongly 
alkaline  in  reaction  owing  to  the  presence  of  carbonate  of 
sodium.  It  contains  four  special  ferments,  each  of  which 
exercises  an  important  influence  upon  digestion.  The  dias- 
tatic  ferment,  or  amylopsin,  is  very  similar  in  its  action  to 
ptyalin,  and  at  the  temperature  of  the  body  rapidly  converts 
starch  into  maltose,  and  achroodextrin  into  sugar.  The 
proteolytic  ferment,  trypsin,  is  most  active  in  an  alkaline 
medium,  although  it  is  not  entirely  inhibited  by  a  slight  degree 
of  acidity,  and  changes  the  proteids  that  have  escaped  solution 
in  the  stomach  into  peptones.  Some  of  the  intermediate  prod- 
ucts of  digestion  undergo  bacterial  putrefaction,  with  the 
ultimate  production  of  indol,  skatol,  volatile  fatty  acids  and 
various  gases. 

The  action  of  the  pancreatic  juice  upon  neutral  fats  is 


NORMAL   AND   ABNORMAL   DIGESTION.  413 

twofold:  it  produces  a  fine  permanent  emulsion  and  also  splits 
a  portion  into  glycerin  and  the  corresponding  fatty  acids, 
the  latter  result  being  due  to  the  fat-splitting  ferment,  steapsin. 
The  fatty  acids  thus  liberated  are  partially  saponified  by  the 
alkalies  of  the  pancreatic  and  intestinal  fluids  and  partially 
emulsionised.  The  milk-curdling  ferment  is  probably  most 
active  in  early  life. 

The  succus  entericus,  the  functions  of  which  have  long 
been  a  puzzle  to  physiologists,  has  recently  been  investigated 
anew  with  much  success  by  Pawlow  and  his  assistants.  It 
would  appear  that  this  secretion  is  only  poured  out  in  an  active 
state  in  the  presence  of  chyme,  and  that  its  special  ferment, 
to  which  the  name  enterokinase  has  been  given,  is  to  a  great 
extent  dependent  upon  the  presence  of  pancreatic  juice  in  the 
bowel.  It  has  already  been  noticed  that  bile  is  the  great  ad- 
juvant of  the  fat-splitting  ferment  of  the  pancreas,  and  it  is 
now  known  that  enterokinase  acts  as  an  accentuator  of  the  var- 
ious ferments  of  the  same  gland,  but  more  especially  of  trypsin. 
It  has  also  been  found  that  while  the  secretion  produced  by 
the  mucous  membrane  of  the  whole  of  the  small  intestine  aug- 
ments the  digestive  powers  of  the  entire  pancreatic  secretion, 
that  of  the  duodenum  exerts  the  greatest  influence  upon  pro- 
teolysis, the  activity  of  which  it  increases  to  a  remarkable 
degree.  These  facts  possess  a  certain  amount  of  clinical 
interest  in  connection  with  the  effects  of  chronic  duodenal  in- 
flammation and  atrophy  upon  the  digestion  of  the  albuminous 
constituents  of  the  food. 

The  alimentary  canal,  and  more  particularly  the  large 
bowel,  teems  with  micro-organisms  the  numbers  and  species 
of  which  are  liable  to  vary  under  different  conditions.  It 
was  formally  supposed  that  the  presence  of  bacteria  was  essen- 
tial to  intestinal  digestion,  and  the  results  of  certain  researches 
were  supposed  to  prove  that  a  sterile  bowel  is  incompatible 
with  perfect  health.  The  more  recent  experiments  of  Metch- 
nikoff  appear,  however,  to  controvert  this  view  and  to  suggest 


414  INTESTINAL   INDIGESTION. 

that  the  digestion  of  cellulose,  instead  of  being  effected  by 
bacterial  activity,  is  probably  the  outcome  of  a  special,  though 
at  present  unidentified,  ferment.  It  is  also  possible  that  in 
addition  to  the  various  recognised  infections  of  the  intestine, 
the  accidental  introduction  of  certain  benign  species  may 
stimulate  the  activity  of  the  natural  inhabitants  to  such  a 
degree  as  to  produce  severe  inflammation  or  even  ulceration 
of  ahmentary  tract. 

The  absorption  of  the  products  of  digestion  is  chiefly  carried 
out  by  the  bowel.  Water,  peptones,  and  the  soluble  salts 
necessary  to  nutrition  rapidly  find  their  way  into  the  blood 
and  lymph  vessels  of  the  alimentary  canal,  while  sugars  are 
absorbed  more  slowly  by  the  rootlets  of  the  portal  vein.  It  is 
probable  that  emulsified  fats  and  unchanged  proteids,  in  addi- 
tion to  water,  are  capable  of  being  absorbed  by  the  large  intes- 
tine. The  exact  manner  in  which  fats  pass  into  the  lacteals 
has  not  yet  been  definitely  settled,  but  it  is  certain  that  a  small 
proportion  is  absorbed  in  the  form  of  soluble  soaps  or  as  an 
emulsion.  The  greater  part  of  the  neutral  fats  pass  through 
the  columnar  epithelium  as  emulsified  fatty  acids  and  glycerin, 
which  in  the  wall  of  the  bowel  are  again  synthetised  into  neu- 
tral fats,  while  the  soluble  soaps  which  are  dissolved  in  the 
glycerin  are  reconstituted  in  a  similar  manner. 

Intestinal  digestion  is  so  complex  in  its  character  and 
depends  upon  the  physiological  integrity  of  so  many  different 
tissues,  that  were  it  not  for  the  wonderful  automatic  mechanism 
which  regulates  the  various  functions  of  the  bowel  and  of  the 
glands  that  pour  their  secretions  into  it,  digestion  and  absorp- 
tion would  soon  be  reduced  to  a  state  of  chaos.  This  fact  is 
readily  comprehended  when  the  effects  of  disordered  gastric 
digestion  upon  the  functions  of  the  intestine  are  considered. 
An  excessive  degree  of  gastric  acidity  accompanies  many 
disorders  of  the  stomach,  but  instead  of  immediately  disturb- 
ing the  processes  of  digestion  in  the  bowel,  the  automatic 
adjustment  is  brought  into  force  and  perfect  compensation 


NORMAL    AND    ABNORMAL   DIGESTION.  415 

results.  Thus,  the  preparatory  secretion  is  at  once  increased 
both  in  quantity  and  alkalinity  for  the  purposes  of  neutralisa- 
tion, while  the  augmented  acidity  of  the  duodenal  chyme  acts 
as  a  powerful  stimulant  to  pancreatic  secretion  and  intestinal 
peristalsis.  Even  the  pyloric  spasm  that  accompanies  gastric 
hyperacidity  is  not  entirely  inimical,  since  by  prolonging  the 
period  of  gastric  digestion  it  ensures  a  more  complete  solution 
of  proteids  in  the  stomach  and  affords  time  for  a  greater  ac- 
cumulation of  alkaline  juices  in  the  duodenum.  In  cases  of 
diminished  gastric  acidity,  peptic  digestion  is  seriously  inter- 
fered with,  but  a  much  larger  proportion  of  starch  is  converted 
into  sugar,  and  the  work  of  the  intestine  in  this  respect  is  less- 
ened. Although  this  condition  is  attended  by  a  corresponding 
diminution  in  the  amount  of  bile  and  pancreatic  juice,  com- 
pensation remains  complete  owing  to  the  fact  that  less  alkali 
is  required  for  neutralisation  and  consequently  a  greater  pro- 
portion remains  available  for  the  digestion  of  proteids  and  fats. 
The  intestinal  secretions  also  vary  both  in  quantity  and  quality 
with  the  composition  of  each  meal:  an  excess  of  starch  or  pro- 
teids being  productive  of  increased  amylolytic  or  tryptic 
activity,  while  a  diet  composed  largely  of  fat  chiefly  stimulates 
the  secretion  of  bile  and  steapsin.  These  automatic  adjust- 
ments may  continue  to  work  with  perfect  precision  for  a  con- 
siderable time,  but  sooner  or  later  the  functions  of  the  small 
intestine  and  other  digestive  glands  become  exhausted  and 
the  processes  of  compensation  begin  to  exhibit  signs  of  failure. 
/Under  these  circumstances  fat  is  usually  the  first  constituent^ 
I  of  the  food  to  suffer,  and  its  diminished  absorption  is  evidenced  I 
by  an  increased  evacuation  of  neutral  fats  and  combined  fatty  \ 
acids.  Subsequently  the  proteids  undergo  excessive  putre- 
faction and  finally  the  carbohydrates  are  decomposed  by  bac- 
terial action  and  the  production  of  sugar  is  arrested.  This 
failure  of  compensation  naturally  occurs  at  an  earher  date 
when  the  gastric  disorder  arises  from  organic  disease.  Thus, 
when  subacidity  ensues  from  chronic  gastritis  the  intestine 


41 6  INTESTINAL   INDIGESTION. 

becomes  hampered  not  only  by  the  products  of  abnormal 
fermentation,  but  also  by  the  presence  of  bacteria,  and  con- 
sequently intestinal  inflammation,  accompanied,  perhaps,  by 
an  infection  of  the  biliary  or  pancreatic  ducts,  almost  invari- 
ably develops  and  seriously  interferes  with  the  functions  of 
digestion.  In  like  manner,  a  continuous  and  excessive  hyper- 
acidity of  the  gastric  juice  tends  to  exhaust  the  activity  of  the 
pancreas  and  to  excite  a  form  of  chronic  intestinal  inflammation 
which  eventually  arrests  the  solution  and  absorption  of  food. 

In  addition  to  the  disturbing  influences  of  disordered  gas- 
tric digestion,  the  functions  of  the  small  intestine  are  always 
liable  to  become  deranged  by  any  abnormal  condition  of  the 
colon  or  other  excretory  organs  of  the  body.  Thus,  an  exalted 
neuro-muscular  irritability  of  the  large  intestine,  by  increasing 
the  rapidity  with  which  its  contents  are  eliminated,  tends  to 
hurry  the  chyme  through  the  upper  bowel  and  thus  to  curtail 
the  time  which  is  necessary  for  its  absorption;  while  an  inefii- 
cient  peristalsis  not  only  retards  the  transmission  of  chyme 
through  the  alimentary  canal,  but  also  favours  its  putrefac- 
tion and  the  absorption  of  the  chemical  poisons  which  ensue 
from  it. 

The  whole  of  the  intestinal  tract  is  also  called  upon  to  aid 
in  the  elimination  of  urea  and  other  excrementitious  products 
whenever  the  renal  functions  are  seriously  interfered  with, 
and  is  injuriously  affected  by  the  venous  congestion  that  arises 
from  diseases  of  the  heart  or  lungs  or  from  obstructions  of  the 
portal  circulation;  while  in  itself  it  is  prone  to  various  forms  of 
inflammation,  ulceration,  and  displacement,  all  of  which  mate- 
rially hamper  its  physiological  activity.  Finally,  the  proc- 
esses of  intestinal  digestion  are  at  all  times  dependent  upon 
the  integrity  of  the  liver  and  pancreas,  since  any  perversion  of 
these  glands  interferes  at  once  with  the  chemical  elaboration 
of  the  food.  Many  of  these  morbid  conditions  cannot  be 
detected  by  the  clinical  methods  at  present  in  vogue,  and 
in  the  limited  state  of  our  knowledge  it  is  necessary  to  concen- 


ETIOLOGY.  417 

trate  our  attention  upon  such  disorders  as  permit  of  clear  defi- 
nition and  easy  recognition.  I  therefore  purpose  to  consider 
in  the  first  place  intestinal  digestion  in  its  entirety,  and  subse- 
quently the  three  principal  subdivisions  of  the  complaint  the 
symptoms  of  which  arise  either  from  a  deficient  supply  of  bile 
or  pancreatic  juice  or  from  a  spasmodic  contraction  of  the 
musculature  of  the  bowel.  To  the  first  of  these  the  term 
chronic  intestinal  indigestion  may  be  applied,  while  the 
others  may  be  described,  respectively,  as  duodenitis,  pancreat- 
itis, and  enterospasm.  The  principal  features  of  intestinal 
neurasthenia  have  already  been  noticed  under  the  gastric  dis- 
order of  that  name,  while  the  clinical  phenomena  of  enterop- 
tosis  are  practically  identical  with  those  which  accompany 
gastroptosis. 

I.  CHRONIC  INTESTINAL   INDIGESTION. 

Etiology. — The  causation  of  indigestion  in  the  intestinal 
canal  may  be  discussed  upon  the  same  lines  as  those  laid 
down  in  the  case  of  gastric  dyspepsia.  It  must  always  be 
remembered,  however,  that  the  failure  of  one  function  in- 
variably leads  to  the  disorder  of  another,  and  that  whatever 
may  be  the  nature  of  the  primary  perversion,  all  the  other 
functions  of  the   bowel    will    eventually   become    deranged. 

Disorders  of  secretion  concern  not  only  the  glands  of  the 
intestinal  mucous  membrane,  but  also  the  liver  and  pancreas. 
In  the  former  case,  a  deficiency  of  succus  entericus  is  probably 
accompanied  by  diminished  tryptic  activity  and  enfeeblement 
of  the  powers  of  absorption,  while  a  decrease  in  the  amount 
of  bile  lessens  the  digestion  of  fats,  and  failure  of  the  pancreatic 
juice  puts  a  stop  to  all  the  more  important  processes  of  digestion. 

Inflammations  of  the  intestine  arise  from  many  different 

causes  and  either  continue  simple  in  character  or  proceed  to 

ulceration   or   atrophy   of   the   mucous   membrane.     In   the 

latter  case,  the  food  not  only  undergoes  excessive  decom- 

27 


41 8  CHRONIC   INTESTINAL   INDIGESTION. 

position,  but  is  hurried  through  the  canal  before  the  alimentary- 
substances  which  might  still  prove  of  value  to  the  economy- 
are  capable  of  being  absorbed.  The  febrile  condition  which 
accompanies  many  forms  of  enteritis  also  exerts  a  pernicious 
influence  upon  the  glandular  structures  of  the  stomach  and 
pancreas,  so  that  eventually  the  secretions  of  these  important 
viscera  become  valueless  for  the  purposes  of  digestion. 

Weakness  of  the  muscular  coat  of  the  bowel  {myasthenia) 
induces  excessive  putrefaction  of  the  contents  of  the  alimentary 
canal,  the  gaseous  products  of  which  distend  and  stretch  the 
already  enfeebled  tissues  and  further  increase  the  disorder. 
Many  of  the  poisons  that  are  formed  by  the  decomposition 
of  food  are  absorbed  into  the  circulation  and  are  subsequently 
eliminated  by  the  bile,  whose  functions  become  impaired  in 
the  process.  The  frequent  coexistence  of  gastric  myasthenia 
also  throws  an  additional  strain  upon  the  pancreatic  secretion, 
which  is  apt  to  suffer  still  further  from  the  development  of 
secondary  inflammation  of  the  duodenum. 

The  various  nervous  disorders  of  the  alimentary  tract 
derange  the  peristaltic  movements  of  the  bowel,  induce  gaseous 
distention  of  its  coils,  diminish  its  powers  of  absorption  or 
impair  the  secretory  activity  of  its  glands;  while  the  severe 
pain  with  which  they  are  sometimes  accompanied  destroys 
appetite,  interferes  with  sleep,  and  induces  a  state  of  general 
ill  health  which  is  prejudicial  to  digestion. 

Foreign  bodies  are  seldom  met  with  in  the  intestine,  but 
the  numerous  worms  and  other  parasites  which  occasionally 
inhabit  the  bowel  sometimes  give  rise  to  pain  and  other 
symptoms  of  indigestion  or  even  excite  chronic  inflammation. 
Intestinal  indigestion  invariably  ensues  when  other  important 
viscera  are  affected  by  disease.  Thus,  organic  mischief  of 
the  heart,  lungs,  liver,  and  spleen  is  always  accompanied  by 
impairment  of  secretion  and  absorption,  and  chronic  inflam- 
mation of  the  kidneys  gives  rise  to  a  form  of  enteritis  that  is 
often  associated  with  ulceration.     Ansemia  and  other  abnormal 


SYMPTOMS.  419 

states  of  the  blood  are  usually  attended  by  atony  of  the  colon, 
while  syphilis  and  many  specific  fevers  develop  gastro- 
enteritis during  their  febrile  manifestations. 

Symptoms. — The  clinical  picture  of  chronic  intestinal 
indigestion  is  very  difficult  to  delineate  on  account  of  the  mixed 
lesions  that  are  concerned  and  the  numerous  symptoms  of 
secondary  origin.  In  the  great  majority  of  cases  deterioration 
of  the  general  health  and  malnutrition  constitute  the  most 
important  evidences  of  ill  health,  and  it  is  only  after  careful 
enquiry  that  the  true  nature  of  the  complaint  becomes 
manifest. 

The  disorder  affects  both  sexes  and  occurs  at  all  ages,  but 
it  originates,  perhaps,  most  frequently  within  the  first  two 
decades  or  after  middle  life.  In  the  former  case,  inflammation 
of  the  bowel  is  the  usual  cause  of  indigestion,  but  in  the  latter, 
disease  of  the  pancreas,  liver,  or  other  important  organs  of  the 
body  is  primarily  responsible  for  it. 

Diminution  of  energy,  failure  of  interest,  debility,  insomnia, 
and  a  gradual  loss  of  flesh  constitute  the  main  causes  of 
complaint,  while  the  patient's  relatives  almost  invariably  com- 
ment upon  his  irritabihty  of  temper,  moodiness,  capricious 
appetite,  disinclination  for  exertion,  or  a  tendency  to  hypo- 
chondriasis. Vague  pains  in  the  back,  neck,  shoulders,  and 
head  so  often  exist  that  they  cannot  be  regarded  as  purely 
accidental,  and  should  receive  more  attention  than  is  usually 
accorded  to  them.  In  long-standing  cases  the  skin  often 
exhibits  a  sallow,  unhealthy  appearance  and  the  surface  of 
the  body  exhales  an  unpleasant  odour  and  is  apt  to  become 
bathed  in  sweat  from  slight  exertion,  annoyance,  excitement, 
or  even  after  the  ingestion  of  a  cup  of  tea  or  other  hot  fluid. 
When  the  functions  of  the  pancreas  are  seriously  at  fault, 
the  complexion  presents  the  characteristic  clay-coloured  tint, 
which  deepens  to  yellow  from  time  to  time.  The  hands  and 
feet  are  cold  and  clammy,  the  pulse  is  full,  slow,  and  feeble, 
and  reference  is  frequently  made  to  a  deficient  ehmination  of 


420  CHRONIC   INTESTINAL   INDIGESTION. 

urine  or  to  the  constant  cloudiness  and  strong  odour  of  the 
fluid. 

Sleep  is  either  broken  or  unrefreshing,  or  is  replaced  by  a 
form  of  stupor  in  which  the  brain  appears  to  remain  abnor- 
mally active.  Many  individuals  suffer  from  headache  or 
drowsiness  after  every  meal,  and  may  only  shake  off  their 
apathy  toward  evening  or  when  it  is  time  to  retire  to  rest. 

The  special  symptoms  of  the  disorder  are  usually  as  vague 
as  those  of  the  general  ill  health.  As  a  rule,  however,  there  is  a 
constant  sense  of  weight  or  uneasiness  in  the  left  iliac  fossa 
which  sometimes  is  described  as  actual  pain.  Discomfort 
in  the  early  morning  sufficiently  noticeable  to  wake  the  patient 
or  to  prevent  further  sleep  is  a  common  and  very  suggestive 
symptom,  and  is  not  infrequently  attended  by  a  desire  to  pass 
water  or  to  evacuate  the  bowels.  A  call  to  stool  may  result 
only  in  the  noisy  expulsion  of  a  large  quantity  of  foul-smelling 
flatus,  but  in  many  instances  the  passage  of  a  pultaceous  motion 
is  followed  by  immediate  relief.  During  the  process  of  dress- 
ing, the  whole  abdomen  sometimes  feels  inflated  and  tender, 
and  difficulty  may  be  experienced  in  adjusting  the  corsets, 
owing  to  a  temporary  enlargement  of  the  waist.  This  con- 
dition is  usually  accompanied  by  a  foul  taste  in  the  mouth, 
headache,  nausea,  giddiness,  and  the  eructation  or  passage 
of  gas.  Breakfast  may  serve  to  relieve  these  various  symp- 
toms, but  as  a  rule  abdominal  discomfort  and  distention  recur 
within  one  or  two  hours,  attended,  perhaps,  by  colicky  pains 
in  the  region  of  the  umbilicus  or  in  the  descending  colon. 
Other  patients  suffer  much  annoyance  from  loud  rumblings 
in  the  belly  at  different  times  of  the  day  and  the  constant 
passage  of  flatus.  Mental  worry,  fatigue,  excitement,  or 
exposure  to  cold  almost  invariably  causes  an  acute  exacer- 
bation of  all  these  abdominal  symptoms  and  sometimes  gives 
rise  to  extreme  nausea.  The  state  of  the  bowels  varies  accord- 
ing to  the  chronicity  and  the  exact  nature  of  the  disorder.  As 
a  rule,  constipation  exists  during  its  earlier  stages,  and  much 


SYMPTOMS.  421 

relief  is  afforded  by  the  use  of  aperients;  but  with  the  progress 
of  the  complaint  the  stools  tend  to  become  loose  and  eventu- 
ally diarrhoea  is  a  prominent  feature  of  the  case.     This  latter 
/  "condition  is  most  often  encountered  if  the  digestion  of  fat  is^ 
1  at  fault,  when  the  motions  are  soft  or  pultaceous,  pale  in  col-  ' 
\our,  and  have  a  peculiar  acid  smell.     Excessive  carbohydrateX 
fermentation  is  usually  accompanied  by  spasmodic   griping) 
/and  the  passage  of  sour  and  offensive  stools,  while  interference! 
/'with  proteid  digestion  gives  rise  to  much  flatus  and  the  dejecta 
Ismell  as  though  affected  with  decay.     The  state  of  the  gastric 
^  digestion  varies   considerably  in   different  cases,   pancreatic 
and  biliary  disorders  being  usually  attended  by  hyperacidity, 
and    inflammation    of    the    intestines    by    gastritis.     Faeces 
coated  with  slime  usually  indicate  chronic  constipation,  and 
the  presence  of  balls  or  strings  of  mucus  in  the  stools  is  a  com- 
mon   feature    of    colitis.     Gelatinous,    bile-stained    motions 
voided  immediately  after  meals  often  serve  to  locate  the  func- 
tional disorder  in  the  jejunum,  while  the  mucus  derived  from 
the  caecum  and  ascending  colon  is  intimately  mixed  with  f^cal 
material,  but  is  free  from  bile.     The  chemical  reaction  of  the 
stools  varies  according  to  the  nature  of  the  complaint :  deficient 
proteid  digestion  is  accompanied  by  alkaline  stools  and  inter- 
ference with  the  absorption  of  fats  or  excessive  fermentation 
of  carbohydrates  by  an  acid  reaction  of  the  dejecta.     The 
appetite  is  almost  always  imparled,  and  there  is  sometimes  a 
marked  distaste  for  those  constituents  of  the  food  whose  diges- 
tion is  disturbed.     This  is  particularly  the  case  in  diseases 
of  the  liver  and  pancreas,  the  subjects  of  which  may  express 
the   greatest  repugnance  to   fats,  oils,  and  eggs,  and  sufl'er 
from   severe   nausea,   flatulence,  or  acidity  after   partaking 
of  them.     Thirst  is  sometimes  such  a  conspiciuous  feature 
as  to  suggest  glycosuria.     As  a  rule,  the  tongue  is  coated  with 
a  white  or  brownish  fur,  which  partially  clears  away  during  the 
course  of  the  day;  the  breath  is  offensive,  and  in  many  cases 
a  chronic  nasopharyngitis  exists,  which  is  very  difficult  to  cure 


422  CHRONIC   INTESTINAL   INDIGESTION. 

as  long  as  the  intestinal  disorder  continues.  The  urine  is 
diminished  in  quantity  and  deposits  an  excess  of  phosphates 
on  standing.  In  many  cases  of  mixed  intestinal  indigestion 
I  have  observedj:onstant  slight  albuminuria,  which  diminishes 
or  disappears  when  the  condition  of  the  bowel  improves  and 
is  usually  accompanied  by  an  unusual  degree  of  general  debility 
and  anaemia.  No  casts  or  other  indications  of  renal  inflamma- 
tion exist.  Sugar  or  the  pancreatic  reaction  may  be  detected 
in  some  cases.  Long-continued  intestinal  indigestion  is  always 
attended  by  steady  loss  of  flesh,  and  in  most  instances  by  a 
progressive  anaemia  which  is  characterised  by  a  diminution 
both  of  red  corpuscles  and  haemoglobin.  In  cases  of  gastro- 
intestinal atrophy,  secondary  to  chronic  inflammation,  the 
state  of  the  blood  closely  resembles  that  of  pernicious  anaemia. 
Irritation  of  the  skin  often  accompanies  deficient  digestion  of 
fats,  and  is  especially  troublesome  when  sallowness  of  the  com- 
plexion suggests  slight  obstruction  of  the  common  bile-duct. 
In  other  cases  attacks  of  urticaria  coincide  with  every  exacer- 
bation of  the  digestive  disorder,  or  patches  of  dry  eczema 
affect  different  parts  of  the  body.  Loss  of  hair  and  premature 
baldness  are  a  noticeable  feature  in  some  instances.  Among 
the  minor  and  less  constant  symptoms,  periodic  headaches, 
like  those  of  migraine,  attacks  of  giddiness  or  faintness,  palpi- 
tation, noises  in  the  head,  persistent  nausea,  numbness  of  the 
fingers,  and  loss  of  memory  are  especially  noteworthy. 

Physical  Signs. — The  abdomen  is  usually  slightly  dis- 
tended, soft,  doughy,  and  easy  to  manipulate,  but  should  the 
intestines  happen  to  be  unduly  inflated  it  may  exhibit  the 
tense  and  tympanitic  condition  which  is  so  suggestive  of 
obstruction.  In  such  cases,  however,  much  flatus  is  passed 
and  the  bowels  act  under  the  influence  of  suitable  aperients. 
Tenderness  on  palpation  rarely  exists  in  the  absence  of  secon- 
dary inflammation  or  ulceration.  When  the  colon  is  chiefly 
affected,  its  transverse  portion  may  be  visible  on  inspection, 
or  an  ill-defined  swelling  may  be  observed  in  the  region  of  the 


PHYSICAL   SIGNS.  423 

caecum  or  sigmoid  flexure.  These  indications  of  local  dis- 
tention are  not  accompanied  by  pain  nor  do  they  exhibit  the 
peristaltic  movements  which  characterise  a  hypertrophied 
coil  of  gut  in  front  of  a  stricture,  and  they  either  subside 
spontaneously  with  a  slight  noise  or  disappear  after  manipu- 
lation or  friction  of  the  skin.  Most  sufferers  from  chronic 
indigestion  in  the  bowels  complain  of  loud  rumblings  or 
gurglings,  which  are  particularly  troublesome  after  meals  or 
are  excited  by  physical  exertion,  respiratory  efforts,  or  a  mental 
emotion,  and  in  almost  every  instance  minor  splashings, 
bubblings,  or  sizzling  sounds  are  audible  when  a  stethoscope 
is  placed  upon  the  abdomen.  If  emphysema  exists,  the  edge 
of  the  liver  may  project  several  inches  below  the  costal 
margin,  and  a  moderate  downward  dislocation  of  the  stom- 
ach, intestines,  and  right  kidney  may  be  detected.  The 
anus  is  often  patulous  and  the  rectum  more  capacious  than 
normal  and  its  mucous  surface  unusually  smooth,  while  not 
infrequently  piles  or  fissure  are  found  to  have  existed  for  a 
considerable  time. 

The  progress  of  digestion  in  the  alimentary  canal  may 
be  investigated  by  duodenal  intubation,  by  Einhorn's  bead- 
test,  and  by  chemical  analysis  of  the  excreta. 

Intubation  of  the  duodenum,  as  practised  by  Hemmeter, 
consists  of  the  introduction  into  the  stomach  of  a  distensible 
bag  along  the  upper  margin  of  which  runs  a  small  tube  that 
can  be  pushed  through  the  pylorus.  This  method  has  not 
been  extensively  used  up  to  the  present  and  it  is  very  doubtful 
whether  an  examination  of  the  contents  of  the  duodenum  will 
throw  much  light  upon  the  chemical  elaboration  of  the  food 
in  the  upper  bowel. 

Einhorn  has  invented  an  ingenious  method  of  testing  the 
activity  of  the  different  ferments  of  the  pancreas.  It  consists 
of  a  gelatin  capsule  containing  several  beads  that  are  strung 
together  on  a  silk  thread  and  to  each  of  which  one  or  two 
pieces  of  the  substances  to  be  examined  are  attached.     These 


424  CHRONIC   INTESTINAL   INDIGESTION. 

test  materials  consist  of  catgut,  fishbone,  meat,  potato,  fat, 
and  thymus,  the  first  two  of  which  are  normally  dissolved  in 
the  stomach  and  the  rest  in  the  intestines.  The  string  of 
beads  usually  appears  in  the  stools  within  forty-eight  hours 
after  the  capsule  has  been  swallowed.  If  they  are  evacuated 
within  twenty-four  hours  the  motility  of  the  bowel  is  increased, 
while  a  delay  beyond  two  days  indicates  diminished  motility. 
Inspection  of  the  test  substances  shows  whether  they  have 
been  digested  or  not,  from  which  the  activity  of  the  different 
processes  of  digestion  may  be  inferred. 

Undoubtedly  the  most  accurate  method  of  investigating 
intestinal  digestion  is  that  of  faecal  analysis.  It  is,  however,  a 
tedious  process  and  one  that  requires  considerable  experience 
and  the  expenditure  of  much  care.  For  the  purposes  of  com- 
parison with  the  normal,  it  is  necessary  to  give  the  patient  a 
special  diet  the  composition  of  which  is  known,  and  to  examine 
the  total  amount  of  the  excreta  which  result  from  it.  It  is 
also  advisable  to  administer  a  dose  of  charcoal  both  before 
and  after  the  experiment,  and  to  collect  for  analysis  all  the 
fasces  which  are  passed  between  the  two  appearances  of 
charcoal  in  the  stools. 

Various  forms  of  diet  are  employed,  but  that  recommended 
by  Schmidt  is  the  most  convenient,  and  is  as  follows: 

7.30  A.M. — Milk,  17  1/2  oz.  and  6  rusks. 

9  A.M. — Gruel  made  from  i  1/2  oz.  of  oatmeal,  1/2  oz.  of 
butter,  7  oz.  of  milk,  10  i  [2  oz.  of  water,  i  egg,  and  2  biscuits. 

I  P.M. — 4  1/2  oz.  of  minced  beef  (weighed  raw),  Hghtly 
fried  in  i  /2  oz.  of  butter,  and  potato  puree  made  from  4  oz. 
of  mashed  potatoes,  7  oz.  of  milk,  and  i  /2  oz.  of  butter. 

4  P.M. — 17  1/2  oz.  of  milk. 

7 .30  P.M. — Same  as  at  9  a.m. 

This  diet  contains  102  grm.  of  proteid,  in  grm.  of  fat,  and 
191  grm.  of  carbohydrates,  equivalent  to  2297.37  calories. 
The   average   daily   weight   of   faeces  which  result  from   it. 


CHEMICAL   ANALYSIS    OF   THE    F^CES.  425 

amounts  to  89.8  grm.,  which  contain  about  76  per  cent,  of 
water. 

Chemical  Analysis  of  the  Faeces. — i.  The  Estimation  of 
Nitrogen  {KjeldahVs  Method). — A  weighed  quantity  of  the 
mixed  faeces  is  placed  in  a  capsule  and  a  decinormal  solution  of 
sulphuric  acid  is  poured  over  it  in  the  proportion  of  20  c.c.  to 
each  100  gram,  of  moist  faeces  in  order  to  prevent  any 
loss  of  ammonia  in  the  process  of  drying.  The  capsule  is  then 
placed  over  a  water-bath  and,  with  frequent  stirring,  is  al- 
lowed to  dry  until  the  faeces  are  fairly  hard.  The  capsule  is 
then  removed,  placed  in  a  hot-air  oven  at  60°  F.  for  two  hours, 
and  cooled  over  sulphuric  acid  in  a  desiccator.  The  contents, 
when  cool,  are  transferred  to  a  mortar  and  ground  into  a  fine 
powder.  One  gram  of  this  powder  is  then  placed  in  a  Kjel- 
dahl's  destruction  flask  with  25  c.c.  of  strong  sulphuric  acid 
and  I  grm.  of  sodium  pyrophospate.  The  flask  is  allowed 
to  stand  for  a  few  hours  and  is  then  heated  over  a  Bunsen 
burner.  The  heat  must  at  first  be  gentle.  The  contents  of 
the  flask,  having  been  heated  until  they  are  quite  colourless,  are 
allowed  to  cool.  By  this  process  all  the  nitrogen  present  in 
the  faeces  is  converted  into  ammonium  sulphate  and  the  organic 
matter  destroyed  by  oxidation. 

The  cold  contents  of  the  flask  are  carefully  washed  with 
about  600  c.c,  of  water,  a  few  granules  of  zinc  are  added,  and 
a  strong  solution  of  sodium  hydrate  is  mixed  with  the  material 
until  the  reaction  becomes  alkaline.  The  flask  is  then  con- 
nected with  a  distillation  apparatus  and  distillation  carried  on 
until  all  the  ammonia  present  in  the  flask  has  passed  into  a 
receiver  containing  a  measured  quantity  of  decinormal  solution 
of  sulphuric  acid,  with  which  it  forms  sulphate  of  ammonium. 
The  acid  solution  is  then  triturated  with  the  decinormal  solu- 
tion of  sodium  until  neutrahsation  has  been  effected,  and  the 
amount  of  the  alkaline  solution  used  for  this  purpose  having 
been  subtracted  from  the  original  amount,  the  remainder  will 
give  the  quantity  of  sulphuric  acid  which  has  been  neutralised 


426  CHRONIC   INTESTINAL   INDIGESTION. 

by  the  ammonia  distilled  over,  from  which  the  total  nitrogen 
present  in  the  faeces  can  easily  be  computed. 

The  nitrogen  of  the  faeces  is  not  entirely  derived  from  the 
food,  but  also  arises  in  part  from  the  epithelium  of  the  mucous 
membrane,  the  elements  of  the  various  secretions,  mucus,  and 
bacteria.  After  Schmidt's  diet,  Harley  and  Goodbody  found 
the  quantity  of  nitrogen  eliminated  in  the  faeces  averaged  o .  88 
grm.  per  diem.  It  is  very  doubtful  whether  the  estimation  of 
nitrogen  has  any  practical  bearing  upon  diagnosis. 

2.  The  Estimation  of  Fats  (Cammidge). — Two  clean, 
dry,  Schmidt-Stokes  milk-tubes,  labelled  A  and  B  and  pro- 
vided w^ith  a  lo  c.c.-mark,  are  taken,  and  into  the  lower  bulb 
of  each  is  introduced  an  accurately  weighed  quantity  (about 
half  a  gram)  of  finely  powdered  faeces  that  have  been  dried 
to  a  constant  weight  on  a  water-bath.  The  residue  on  the 
watch-glass  used  for  weighing,  and  on  the  sides  of  the  short- 
necked  funnel  with  which  the  powder  is  introduced  into  the 
tube,  is  washed  down  with  a  fine  jet  from  a  wash-bottle,  which 
for  the  A  tube  contains  hydrochloric  acid  (1:3)  and  for  the 
B  tube  plain  water.  The  sides  of  the  tube  are  also  washed 
until  the  whole  of  the  sample  is  collected  in  the  lower  bulb, 
and  the  10  c.c.-mark  is  reached.  The  A  tube  is  then  heated 
in  boiling  water  for  twenty  minutes,  occasionally  rotating  it  so 
as  to  well  mix  the  contents.  After  cooling,  both  tubes  are 
filled  to  the  50  c.c.-mark  with  ether,  securely  corked  and  in- 
verted forty  times,  taking  care  that  the  whole  of  the  solid 
material  runs  through  at  each  turn.  Each  tube  is  then  rotated 
between  the  hands  and  allowed  to  stand  for  half  an  hour  or 
more,  in  order  that  the  solid  residue  may  be  collected  in  the 
lower  bulb.  Considerable  care  is  necessary  in  carrying  out 
this  part  of  the  process  in  some  instances,  or  a  perfectly  clear 
supernatant  layer  of  ether,  free  from  solid  particles,  is  not 
secured.  With  a  pipette,  exactly  20  c.c.  of  the  clear  ethereal 
extract  are  drawn  off  from  each  tube  and  dehvered  into  two 
CO2  flasks  of  known  weight,  the  amount  of  ether  left  in  the 


CHEMICAL   ANALYSIS    OF   THE   F^CES.  427 

tubes  being  noted.  The  ether  in  the  flasks  is  then  evaporated, 
the  residue  dried  on  the  water-bath,  and  the  flasks  again 
weighed.  From  the  amount  of  extract  yielded  by  the  20  c.c. 
of  ether,  and  the  quantity  of  ether  left  in  the  tubes,  the  total 
amount  yielded  by  the  weight  of  dried  faeces  used  may  be 
calculated,  and  from  this  the  percentage  in  the  stool  deter- 
mined. The  result  from  the  A  tube  gives  the  total  fat  in  the 
faeces,  including  the  neutral  fats,  free  fatty  acids,  and  com- 
bined fatty  acids,  or  soaps,  since  the  latter  will  have  been 
decomposed  by  being  boiled  with  the  hydrochloric  acid  and 
thus  rendered  soluble;  that  from  the  B  tube  represents  the 
neutral  fats  and  fatty  acids  only,  as  the  soaps  will  remain  un- 
dissolved by  the  ether;  the  difference  between  the  two  will, 
therefore,  give  the  proportion  of  saponified  fat  present. 

The  solid  residue  from  the  B  tube  can  be  used  for  the 
detection  of  stercobilin.  For  this  purpose  it  is  filtered  off, 
extracted  with  acid  alcohol,  the  extract  neutralised  with  ammo- 
nia and  mixed  with  an  equal  quantity  of  10  per  cent,  zinc  ace- 
tate in  alcohol.  The  precipitate  that  forms  is  removed  by  fil- 
tration, and  the  clear  filtrate  examined  with  a  lens,  against  a 
black  background,  for  the  green  fluorescence  that  indicates  the 
presence  of  stercobilin.  The  intensity  of  the  colour  varies 
with  the  amount  of  pigment,  so  that  by  always  using  approxi- 
mately the  same  proportion  of  faeces  and  of  the  reagents  any 
marked  variation  from  the  normal  can  be  detected. 

3.  Estimation  of  the  Carbohydrates . — For  all  clinical  pur- 
poses Schmidt's  method  of  estimating  the  degree  of  fermenta- 
tion in  the  intestines  is  sufl&cient.  About  5  grm.  of  faeces  are 
placed  in  a  fermentation  tube  and  well  mixed  with  water.  A 
small  tube  passes  through  the  rubber  stopper  and  connects  the 
receptacle  with  two  upright  tubes  which  are  connected  by  a 
transverse  pipe,  the  exterior  one  of  which  has  a  small  hole  in 
the  top,  while  that  which  communicates  directly  with  the 
fermentation  tube  is  filled  with  water.  The  apparatus  is 
placed  in  an  incubator  at  a  temperature  of  99°  F.  for  twenty- 


428  CHRONIC   INTESTINAL   INDIGESTION. 

four  hours.  Under  normal  circumstances  the  gas  generated 
by  fermentation  never  fills  more  than  half  of  the  proximal 
tube;  but  if  carbohydrate  digestion  in  the  bowel  is  imperfect, 
a  much  larger  quantity  is  produced,  the  measure  of  which 
affords  a  rough  indication  of  the  degree  of  amylaceous  in- 
digestion. 

Microscopical  examination  of  the  dejecta  permits  the  rec- 
ognition of  an  excess  of  undigested  muscle-fibre,  fat  globules, 
connective  tissue,  flakes  or  needles  of  fatty  acids,  starch  granules, 
and  crystals  of  ammonium  magnesium  phosphate,  triple 
phosphates,  calcium  oxalate,  and  chlolesterin  and  also  those 
known  as  the  Charcot-Leyden  crystals.  The  presence  of 
epithelial  cells  and  leucocytes  may  prove  of  value  in 
diagnosis. 

Treatment. — Warm  clothing  is  essential,  and  a  flannel 
binder  should  always  be  worn  round  the  abdomen.  A  dry, 
bracing  climate  suits  the  majority  of  cases  best.  If  the  dis- 
order is  secondary  to  gastric  hyperacidity,  a  course  of  waters 
at  Vichy,  Ems,  or  Harrogate  may  be  recommended,  while 
those  of  Marienbad  or  Carlsbad  are  most  suitable  for  the 
biliary  and  pancreatic  forms  of  the  complaint.  The  symptoms 
of  chronic  colitis  are  often  much  improved  by  a  visit  to  Plomb- 
ieres  or  to  some  watering-place  where  a  similar  form  of  treat- 
ment is  carried  out. 

Diet. — A  careful  examination  of  the  faeces  should  be  made 
in  every  case  in  order  to  determine,  as  far  as  possible,  the 
relative  digestion  of  the  various  constituents  of  the  food.  An 
excess  of  fat  in  the  motions  usually  indicates  pancreatic  or 
biliary  disturbance,  the  nature  of  which  may  be  recognised  by 
the  presence  of  their  characteristic  symptoms.  In  such  con- 
ditions fat  meats,  oily  fish,  eggs,  and  cream  should  be  ehminated 
from  the  dietary  and  milk  be  given  with  caution.  Excessive 
carbohydrate  fermentation  indicates  the  necessity  of  restricting 
the  amount  of  starch  and  of  substituting  thin  toast,  rusks  or 
the  Brusson-Jeune  rolls  for  ordinary  bread.     Sugars  may  be 


TREATMENT.  429 

allowed  in  moderation  and  the  various  malted  and  semi-digested 
cereal  foods  are  sometimes  employed  with  advantage.  The 
total  exclusion  of  carbohydrates  has  been  recommended  by 
several  writers  (Schmidt,  Meyer),  but  such  prohibition  is 
seldom  advisable.  Clear  soups,  purees  of  potato,  peptonised 
milk,  koumiss,  curdled  milk,  pancreatised  foods,  maltine, 
sanatogen,  weak  tea  and  cocoa  may  be  allowed,  but  malt 
liquors  and  alcohol  rarely  agree.  Hot  water,  mild  alkaline 
mineral  waters,  and  fresh  lemonade  may  be  drunk  with  the 
meals.  Green  vegetables  and  uncooked  fruits  must  be  strictly 
forbidden,  but  potatoes,  seakale,  stewed  celery,  and  cauh- 
flower  may  be  permitted  in  moderation.  With  excessive  proteid 
putrefaction  chicken,  game,  and  fish  should  be  given  instead 
of  mutton,  beef,  or  veal.  When  catarrh  of  the  intestine  or 
gastric  subacidity  is  present,  a  prolonged  course  of  milk,  cur- 
dled in  the  manner  recommended  by  Metchnikoff,  is  often  of 
the  greatest  service,  a  pint  or  more  being  taken  each  day. 
When  it  agrees,  not  only  do  the  symptoms  of  indigestion 
abate  in  a  remarkable  manner,  but  the  general  nutrition  im- 
proves and  the  diarrhoea  disappears.  I  have  never  observed 
any  good  to  ensue  from  the  administration  of  the  tablets  or 
powders  of  the  dried  bacilli  nor  of  sweets  which  are  supposed  to 
contain  the  lactic  organisms  in  an  active  state. 

Medicinal. — Drugs  are  administered  with  three  objects, 
namely,  to  assist  digestion,  to  counteract  intestinal  fermenta- 
tion, and  to  regulate  the  action  of  the  bowels.  Artificial  digest- 
ives are  of  limited  value,  and  pepsin,  papain,  hydrochloric 
acid,  and  other  adjuvants  of  gastric  digestion  are  useless  when 
the  disorder  is  situated  in  the  intestine.  On  the  other  hand, 
the  pancreatic  preparations  and  Holadin  sometimes  appear 
to  be  beneficial,  or  takadiastase  may  be  prescribed  with  advan- 
tage in  amylaceous  indigestion.  Eunatrol  and  oleate  of  sodium 
are  of  distinct  value  when  there  is  reason  to  suspect  a  deficient 
elimination  of  bile.  Pills  containing  dried  gall  or  soap  are 
strongly  advocated  by  some  practitioners.     Excessive  intesti- 


430  CHRONIC   INTESTINAL   INDIGESTION. 

nal  fermentation  usually  indicates  the  necessity  of  antiseptics, 
of  which  the  most  reliable  are  carboHc  acid,  creasote,  guaiacol, 
and  bismuth  salicylate.  The  first-named  may  advantageously 
be  combined  with  nitrohydrochloric  acid  and  glycerin,  while 
guaiacol  is  given  in  the  form  of  capsules.  Creasote,  in  combi- 
nation with  podophyllin  and  rhubarb,  forms  a  pill  suitable 
for  almost  every  case  in  which  constipation  exists,  and  it  also 
helps  to  clean  the  tongue  and  improve  the  appetite.  The 
bismuth  salt  is  chiefly  indicated  when  diarrhoea  exists,  and  if 
combined  with  the  compound  powder  of  opium  serves  to 
relieve  the  griping  pains  in  the  abdomen. 

Resorcine  is  chiefly  of  value  in  children.  A  few  drops  of 
Vanadine  administered  after  each  meal  should  be  tried  when 
other  remedies  fail.  Salol,  naphthol,  and  the  salts  of  strontium 
are  also  favourite  remedies.  Half  a  grain  of  grey  powder  or 
a  sixth  of  a  grain  of  calomel  administered  night  and  morn- 
ing is  often  successful  in  controlling  fermentation  in  the 
intestines,  and  should  always  be  given  in  refractory  cases, 
or  a  drachm  of  the  solution  of  perchloride  of  mercury  may 
be  prescribed  twice  a  day  after  meals.  Whether  the  disorder 
is  attended  by  constipation  or  diarrhoea,  it  is  advisable  to 
commence  the  medicinal  treatment  by  a  dose  of  castor  oil, 
as  this  simple  expedient  will  often  relieve  the  pain  and  dis- 
tention and  also  stop  the  loose  actions  of  the  bowels.  As 
a  regular  aperient,  a  mixture  of  cascara,  maltine,  and 
glycerin  given  each  night  is  an  excellent  remedy;  while  a 
teaspoonful  of  purified  petroleum,  sold  under  the  name  of 
Lenitol,  is  efficacious  in  some  instances.  Salts  are  chiefly  in- 
dicated when  gastric  hyperacidity  exists  or  the  presence  of  gall- 
stones is  suspected,  and  of  these  a  mixture  in  equal  parts  of 
the  dried  sulphate  and  phosphate  of  sodium  is  the  most  reli- 
able. A  dessertspoonful  dissolved  in  a  tumblerful  of  hot 
water  is  given  one  hour  before  breakfast  and  may  be  pre- 
ceded occasionally  by  a  mercurial  pill  at  night.  Tonics  of 
all  kinds  should  be  prohibited. 


ETIOLOGY.  43 1 

2.  CHRONIC  PANCREATITIS. 

It  is  only  of  recent  years  that  inflammation  of  the  pancreas 
has  become  recognised  as  a  condition  of  frequent  occurrence 
and  of  considerable  clinical  importance,  and  our  present 
knowledge  of  this  obscure  disease  is  chiefly  due  to  the  work 
of  Opie,  Cammidge,  Mayo  Robson,  and  others  who  have 
made  the  organ  the  subject  of  special  research. 

At  an  early  stage  of  the  complaint,  the  inflammatory 
mischief  is  usually  interlobular  or  interacinous  in  its  dis- 
tribution, but  with  the  progress  of  time  the  interstitial  tissue 
becomes  much  increased  in  amount  and  a  more  or  less  diffuse 
cirrhosis  results.  In  typical  cases  the  entire  gland  is  some- 
what enlarged,  its  texture  unduly  hard,  and  its  constituent 
lobules  more  clearly  defined  than  in  the  normal  state;  but 
occasionally  the  disease  is  limited  entirely  to  the  head  of 
the  organ.  On  microscopical  examination  the  increase  of 
fibrous  tissue  between  the  lobules  is  found  to  be  accompanied  by 
an  extensive  destruction  of  the  glandular  acini  and  a  serious 
interference  with  the  blood  supply  of  the  islands  of  Langerhans. 
In  the  interacinar  variety  the  cell-islands  are  involved  at  an 
early  period  of  the  complaint  and  death  may  ensue  from 
diabetes  before  the  gland  exhibits  any  changes  visible  to  the 
naked  eye. 

Etiology. — According  to  Opie,  the  common  bile-duct 
grooved  or  pierced  the  pancreas  in  62  per  cent,  and  passed 
behind  the  gland  in  38  per  cent,  of  the  cases  he  examined. 
It  is  probable,  therefore,  that  in  about  three-fifths  of  all  cases 
where  the  head  of  the  gland  is  enlarged,  symptoms  of  biliary 
obstruction  will  occur,  while  in  the  remaining  two-fifths  this 
complication  will  not  be  observed. 

The  mode  of  entry  of  the  biliary  and  pancreatic  ducts 
into  the  duodenum  is  also  liable  to  at  least  six  variations 
which  are  of  considerable  importance  in  the  causation  and 
symptomatology  of  pancreatitis.  In  the  first,  the  common  duct 
enters  the  ampulla  of  Vater  along  with  the  duct  of  Wirsung; 


432  CHRONIC   PANCREATITIS. 

in  the  second,  the  latter  joins  the  common  bile-duct  some  little 
distance  from  the  bowel  and  the  ampulla  is  absent;  while  in 
the  others  the  two  ducts  either  open  side  by  side  in  the  duo- 
denum without  the  intervention  of  an  ampulla,  or  the  bile- 
duct  is  associated  with  the  accessory  duct  of  Santorini,  and 
the  duct  of  Wirsung  enters  the  bowel  separately.  In  rare 
instances  the  pancreas  possesses  three  distinct  ducts,  only  one 
of  which  is  connected  with  the  bile-duct.  It  will,  therefore, 
be  seen  that  a  primary  infection  of  the  common  bile-duct, 
while  entremely  liable  to  affect  the  pancreas  when  the  main 
duct  of  the  latter  enters  the  duodenum  along  with  it,  is  less 
likely  to  prove  injurious  in  cases  where  the  ducts  remain 
separate.  It  has  also  been  shown  by  Opie  that,  owing  to  a 
deficient  anastomosis  between  the  two  principal  ducts  of  the 
pancreas,  the  duct  of  Santorini  is  rarely  able  to  act  as  an 
efficient  safety-valve  when  an  obstruction  of  Wirsung's  duct 
occasions  retention  of  secretion. 

Chronic  pancreatitis,  in  a  large  proportion  of  the  cases, 
is  caused  by  the  presence  of  a  stone  in  the  lower  end  of  the 
common  bile-duct,  which  either  directly  compresses  and 
irritates  the  tissue  of  the  gland  or  by  inducing  cholangitis 
causes  an  infection  of  the  pancreatic  duct  with  which  it  is 
closely  connected.  In  other  instances,  the  disease  ensues 
from  direct  extension  of  inflammation  from  the  duodenum 
to  the  duct,  it  having  been  proved  by  experiment  that  the 
introduction  of  the  bacillus  coli  or  faecal  material  into  the 
duct  of  Wirsung  is  followed  by  inflammation  of  the  glandular 
tissues.  Chronic  ulcer  of  the  duodenum  or  stomach  is  some- 
times followed  by  pancreatitis  from  the  same  cause,  while  the 
perigastritis  that  ensues  from  gastric  carcinoma  occasionally 
gives  rise  to  an  inflammatory  induration  of  the  organ.  Finally, 
an  attack  of  enteric  fever,  influenza,  syphilis,  or  tuberculosis 
rnay  be  followed  by  the  cHnical  indications  of  pancreatitis, 
while  in  rare  instances  the  chronic  type  of  the  disease  ensues 
from  an  acute  or  subacute  inflammation  of  the  gland. 


SYMPTOMS.  433 

Symptoms. — It  is  usually  the  custom  to  regard  chronic 
inflammation  of  the  pancreas  as  a  condition  which  can  seldom 
be  recognised  during  life.  This,  however,  is  a  mistake,  since 
in  a  very  large  proportion  of  the  cases  the  complaint  may  be 
diagnosed  with  certainty  if  all  the  phenomena  connected  with 
it  be  taken  into  careful  consideration. 

The  general  syniptoms  which  portray  its  existence  vary 
both  in  their  nature  and  severity  according  to  its  cause.  Thus, 
when  gall-stones  constitute  the  primary  complaint,  there  is 
usually  a  history  of  former  attacks  of  paroxysmal  pain  in  the 
right  hypochondrium  and  epigastrium,  followed,  perhaps,  by 
jaundice  or  fever;  while  in  those  instances  where  a  stone  has 
become  impacted  in  the  common  bile-duct  icterus  may  have 
persisted  for  a  considerable  time.  It  is  important  to  remember, 
however,  that  the  lodgment  of  a  calculus  in  the  common  duct 
does  not  necessarily  produce  permanent  jaundice,  since  local 
dilatation  of  the  canal  sometimes  ensues  which  permits  the 
stone  to  float  in  the  secretion  and  thus  to  act  as  a  ball-valve. 
In  cases  of  this  latter  kind  sudden  physical  exertion  or  an 
energetic  peristalsis  of  the  bowel  may  cause  the  stone  to  become 
fixed  in  the  distal  end  of  the  duct,  with  the  result  that  the  in- 
fected secretions  of  the  liver  and  pancreas  are  retained  in  their 
respective  channels. 

Under  these  circumstances  the  patient  experiences  a  general 
malaise,  accompanied  by  chilHness,  shivering,  fever,  and  jaun- 
dice, and  suffers  from  nausea,  flatulence,  headache,  and  loss 
of  appetite.  After  a  few  days'  rest  in  bed,  the  temperature 
usually  falls  and  the  icterus  and  other  symptoms  disappear. 

When  pancreatitis  arises  from  duodenal  ulcer  or  other 
condition  independent  of  cholangitis,  the  complaint  develops 
very  insidiously  and  many  months  or  even  years  may  elapse 
before  its  symptoms  become  sufficiently  serious  to  attract 
attention.  In  such  cases  the  principal  subjective  phenomena 
are  those  of  gastric  and  intestinal  indigestion.  Discomfort 
after  meals,  with  flatulence,  acidity,  nausea,  and  mental  apathy 
28 


434  CHRONIC   PANCREATITIS. 

are  almost  invariably  present,  and  much  dislike  may  be  ex- 
pressed to  fat  and  oily  forms  of  food.  The  ingestion  of  butter, 
meat-fat  and  sometimes  of  cream  and  eggs  greatly  increase  the 
dyspepsia  and  are  liable  to  be  followed  by  vomiting  of  an  oily 
material  which  assumes  the  appearance  of  granular  fat  as  it 
cools.  At  a  later  stage,  colickly  pains  in  the  bowels,  bor- 
borygmi,  and  the  frequent  passage  of  offensive  flatus  add 
materially  to  the  sense  of  general  discomfort.  It  is  also  notice- 
able that  the  patient  is  not  only  anaemic,  but  that  the  colour 
of  his  skin  varies  almost  from  day  to  day,  being  sometimes 
merely  sallow,  while  at  other  times  the  tint  is  distinctly  yellow 
and  attended,  perhaps,  by  brownish  stains  on  the  lower  eyelids, 
malar  bones,  or  temples.  These  abnormal  colorations  of  the 
skin  vary  with  the  severity  of  the  digestive  symptoms  and  are 
accompanied  by  extreme  lassitude,  mental  depression,  and 
cutaneous  irritation.  Occasionally  a  mental  shock,  a  physical 
injury,  or  a  surgical  operation  is  followed  by  melancholia  or 
other  form  of  insanity.  Sooner  or  later  progressive  emacia- 
tion makes  its  appearance,  and  although  the  actual  loss  of 
weight  may  not  exceed  a  few  ounces  each  week,  the  downward 
grade  is  steadily  maintained.  At  this  period  of  the  complaint 
or  even  earlier,  the  constipation  which  had  formerly  been  in 
evidence  is  often  replaced  by  an  irritable  state  of  the  bowels, 
the  evacuations  being  frequent,  large,  white,  offensive,  and 
of  greasy  consistence.  The  urine  is  diminished  in  quantity 
and  may  contain  both  bile  and  sugar. 

The  subsequent  course  of  the  disease  varies  with  its  mode 
of  causation.  When  biliary  calculus  or  cholangitis  exist, 
the  enlargement  of  the  head  of  the  pancreas  is  apt  to  induce 
jaundice,  which  gradually  increases  in  severity  until  the 
skin  acquires  a  uniform  mahogany  hue.  If,  however,  the 
common  bile-duct  happens  to  be  situated  behind  the  gland, 
this  symptom  need  not  develop.  The  disturbance  of  diges- 
tion continues  to  excite  much  discomfort  and  to  increase 
the  tendency  to  malnutrition,  haemorrhages  may  occur  in  the 


PHYSICAL   SIGNS.  435 

skin  or  from  the  mucous  membranes,  and  death  j&nally  ensues 
either  from  exhaustion  or  from  some  intercurrent  condition, 
such  as  diabetes,  biliary  toxaemia,  or  pneumonia.  In  other 
cases,  and  especially  where  the  pancreatic  inflammation  has 
followed  ulcer  of  the  duodenum,  the  symptoms  of  the  primary 
disease  continue  to  take  precedence  of  those  arising  from  the 
secondary  complaint,  and  the  characteristic  indications  of 
gastric  hypersecretion  with  progressive  emaciation  engage  the 
sole  attention,  until  the  accidental  discovery  of  fat  in  the  faeces 
or  a  pancreatic  reaction  in  the  urine  demonstrates  the  co- 
existence of  chronic  pancreatitis.  A  certain  number,  however, 
develop  the  symptoms  of  diabetes  or  insanity,  from  which 
death  ensues  within  a  comparatively  short  space  of  time. 

Physical  Signs. — Examination  of  the  abdomen  rarely 
affords  any  definite  evidence  of  pancreatitis.  Tenderness  on 
pressure  exists  in  about  one-half  of  the  cases  and  may 
only  be  elicited  by  deep  palpation.  When  spontaneous  pain 
exists,  the  recti  muscles  are  often  so  rigid  that  the  most  careful 
manipulation  fails  to  detect  any  enlargement  of  the  gland; 
but  occasionally,  even  without  an  anaesthetic,  the  head  of 
the  pancreas  may  be  felt  as  a  swelling  situated  behind  the 
stomach  and  endowed  with  pulsation  communicated  to  it  by 
the  underlying  aorta.  When  jaundice  exists  without  gall- 
stones, a  painless  enlargement  of  the  gall-bladder  may  some- 
times be  detected.  Jaundice  is  present  in  about  three-fifths 
of  all  cases,  but  in  many  instances  it  is  either  slight  or  inter- 
mittent until  a  late  stage  of  the  complaint.  The  two  principal 
signs  of  diagnostic  importance  are  an  excess  of  fat  in  the 
faeces  and  a  pancreatic  reaction  in  the  urine.  In  advanced 
pancreatic  disease  the  stools  are  large,  white,  soft,  acid  in 
reaction,  and  possess  a  characteristic  smell.  These  peculiarities 
are  due  to  the  abnormal  quantity  of  undigested  fat  they  contain 
and  to  the  excessive  fermentation  that  exists  in  the  lower  bowel. 
White  stools  are  commonly  supposed  to  indicate  an  absence 
of  bile  from  the  intestine,  but  it  is  quite  certain  that  they  also 


436  CHRONIC   PANCREATITIS. 

occur  without  biliary  obstruction  in  cases  where  a  large  excess 
of  neutral  fat  mixed  with  crystals  of  fatty  acids  is  evacuated, 
since  the  extraction  of  the  fat  with  ether  leaves  a  dark 
brown  residue  similar  to  that  obtained  from  normal  faeces 
(Cammidge).  The  existence  of  undigested  muscle  fibre  has 
been  noted  in  several  cases  of  cancer  of  the  pancreas  and  is 
also  met  with  in  severe  examples  of  pancreatitis.  As  a  rule, 
it  can  only  be  detected  by  microscopical  examination,  but 
occasionally  it  is  visible  to  the  naked  eye.  Experiments  con- 
ducted upon  animals  from  which  the  pancreas  has  been  either 
partially  or  entirely  removed,  show  that  only  one-third  to  one- 
half  of  the  proteids  of  the  food  are  absorbed,  and  in  chronic 
pancreatitis  a  similar  proportionate  waste  is  observed.  Very 
rarely  do  the  stools  exhibit  any  indication  of  impaired  starch 
digestion,  although  it  is  certain  that  a  much  diminished  amy- 
lolysis  must  result  from  the  destruction  of  the  pancreatic 
tissue.  It  is  probable  that  in  these  cases  the  starches  are 
slowly  converted  by  bacterial  fermentations  into  maltose 
which  is  subsequently  split  up  into  various  organic  acids  and 
gases. 

By  the  employment  of  his  method,  already  described,  Cam- 
midge has  found  that  chronic  pancreatitis  associated  with 
obstruction  of  the  bile-duct  interferes  almost  as  much  with 
fat  digestion  as  malignant  disease  of  the  pancreas,  where  the 
average  amount  of  total  fat  found  in  the  dried  faeces  was  77  per 
cent.  That  the  high  proportion  of  fat  met  with  in  some  of  these 
cases  is  not  entirely  due  to  the  biliary  obstruction  is  shown  by 
the  fact  that  as  great  an  excess  has  been  found  in  others  in 
which  no  obstruction  to  the  free  flow  of  bile  into  the  intestines 
was  present.  Mild  types  of  pancreatitis  in  which  only  the 
head  of  the  gland  is  affected  are  not  necessarily  accompanied 
by  steatorrhoea.  The  relative  proportions  of  the  neutral  fats 
and  fatty  acids  vary  under  different  conditions. 

The  pancreatic  reaction  (C  reaction)  is  thus  described  by 
Cammidge:  "A  specimen  of  the  twenty-four  hours'  urine  is 


PHYSICAL   SIGNS.  437 

filtered  several  times  through  the  same  filter-paper.  If  it  is 
found  to  be  free  from  sugar  and  albumin  and  is  acid  in  re- 
action, 2  c.c.  of  strong  hydrochloric  acid  (sp.  gr.  1.16)  are 
mixed  with  40  c.c.  of  the  clear  filtrate,  and  the  mixture  gently 
boiled  on  a  sand-bath  in  a  small  flask,  fitted  with  a  funnel 
condenser.  After  ten  minutes'  boiling  the  flask  is  well  cooled 
in  a  stream  of  water,  and  the  contents  made  up  to  40  c.c.  with 
cold  distilled  water.  The  excess  of  acid  is  then  neutrahsed 
by  slowly  adding  8  grm.  of  lead  carbonate.  After  standing 
for  a  few  minutes  to  allow  of  the  completion  of  the  reaction, 
the  flask  is  again  cooled  in  running  water,  and  the  contents 
filtered  through  a  well-moistened,  close-grained  filter-paper 
until  a  perfectly  clear  filtrate  is  obtained.  The  acid  filtrate 
is  then  shaken  with  8  grm.  of  powdered  tribasic  lead  acetate, 
and  the  resultant  precipitate  removed  by  filtration,  as  clear  a 
filtrate  as  possible  being  secured  by  repeating  the  filtration 
several  times  if  necessary.  Since  the  large  amount  of  lead 
now  in  solution  would  interfere  with  the  subsequent  steps 
of  the  experiment,  it  is  removed  either  by  a  stream  of  sul- 
phuretted hydrogen  or  by  precipitating  the  lead  as  a  sulphate. 
For  this  purpose  the  filtrate  is  well  shaken  with  4  grm.  of 
powdered  sodium  sulphate,  the  mixture  heated  to  the  boiling- 
point,  then  cooled  to  as  low  a  temperature  as  possible  in  a 
stream  of  cold  water,  and  the  white  precipitate  removed  by 
careful  filtration.  Ten  cubic  centimeters  of  the  perfectly  clear 
transparent  filtrate  are  taken  and  made  up  to  17  c.c.  with 
distilled  water;  it  is  then  added  to  o .  8  grm.  of  phenylhydrazine 
hydrochlorate,  2  grm.  of  sodium  acetate,  and  i  c.c.  of  a  50 
per  cent,  acetic  acid,  contained  in  a  small  flask  fitted  with  a 
funnel  condenser.  The  mixture  is  boiled  on  a  sand-bath  for 
ten  minutes  and  filtered  hot  through  a  small  filter-paper, 
moistened  with  hot  water,  into  a  test-tube  provided  with  a 
15  c.c. -mark.  Should  the  filtrate  fall  short  of  15  c.c.  it  is 
made  up  to  that  amount  with  hot  distilled  water,  the  added 
water  being  well  mixed  with  the  fluid  by  stirring  with  a  glass 


438  CHRONIC   PANCREATITIS. 

rod.  In  well-marked  cases  of  pancreatitis  a  light  yellow, 
flocculent  precipitate  should  appear  in  a  few  hours,  but  in  less 
characteristic  cases  it  may  be  necessary  to  leave  the  prepara- 
tion overnight  before  a  deposit  occurs.  Under  the  micro- 
scope the  precipitate  is  seen  to  consist  of  long,  light  yellow, 
flexible,  hair-like  crystals  arranged  in  delicate  sheaves,  which 
when  irrigated  with  a  33  per  cent,  solution  of  sulphuric  acid 
melt  away  and  disappear  in  ten  to  fifteen  seconds  after  the 
acid  touches  them."  The  preparation  must  always  be  ex- 
amined microscopically,  as  a  small  deposit  may  easily  be  over- 
looked by  the  naked  eye.  A  positive  reaction  occurs  in 
almost  every  case  of  genuine  chronic  pancreatitis,  but  is  rarely 
met  with  in  disease  of  any  other  organ  of  the  body,  so  that  its 
discovery  may  be  regarded  as  practically  pathognomonic  of 
a  serious  interference  with  the  functions  of  that  gland. 

Diagnosis. — Chronic  pancreatitis  has  chiefly  to  be  distin- 
guished from  cancer  of  the  head  of  the  gland.  In  this  latter 
disease  the  general  failure  of  health  and  loss  of  flesh  are 
early  and  progressive  symptoms,  and  when  jaundice  super- 
venes it  becomes  absolute  and  permanent.  The  gall-bladder 
is  greatly  distended,  but  rarely  tender.  The  liver  is  much 
enlarged,  smooth,  and  painless  owing  to  extreme  engorge- 
ment with  bile.  Occasionally  a  hard,  nodular  growth  lying 
behind  the  stomach  may  be  felt  in  the  region  of  the  navel. 
The  faeces  contain  a  large  amount  of  undigested  fat,  only  a 
comparatively  small  proportion  of  which  consists  of  fatty  acids. 
The  pancreatic  reaction  in  the  urine  (C  reaction)  is  negative 
in  three-quarters  of  the  cases,  but  in  the  remainder  a  more  or 
less  marked  reaction  is  obtained,  probably  as  a  result  of 
secondary  inflammatory  changes  in  the  gland.  Severe,  con- 
stant pain  is  often  experienced  in  the  back,  and  metastatic 
growths  may  develop  in  the  substance  of  the  liver.  The 
emaciation  and  debihty  are  much  more  rapid  than  in  simple 
pancreatitis,  and  death  usually  ensues  within  fifteen  months. 

The  prognosis  of   chronic  interstitial  pancreatitis,  unless 


TREATMENT.  439 

improved  by  operation,  is  extremely  grave,  for  although  life 
may  be  preserved  for  several  years,  death  usually  ensues 
from  asthenia,  diabetes,  haemorrhage,  or  some  other  complaint. 

Treatment. — The  disease  so  often  arises  from  gall-stones, 
duodenal  ulcer,  and  other  conditions  that  are  amenable  to 
medical  treatment,  that  the  possible  sequence  of  pancreatitis  in 
such  complaints  should  always  be  borne  in  mind  and  every 
effort  be  made  to  effect  a  cure  either  by  medicinal  or  surgical 
means.  In  the  various  zymotic  and  constitutional  diseases 
which  are  apt  to  give  rise  to  inflammation  of  the  gland  the 
processes  of  digestion  should  also  be  carefully  watched,  and 
if  obstinate  symptoms  of  dyspepsia  ensue  repeated  examina- 
tions should  be  made  of  the  stools  and  urine  for  indications 
of  disturbed  metabohsm. 

Diet. — Chronic  pancreatitis  usually  affects  all  the  ferments 
of  the  gland  and  especially  that  which  splits  up  the  neutral 
fats.  For  this  reason  care  should  be  taken  to  throw  as  little 
stress  as  possible  upon  the  functions  of  the  organ  by  the 
selection  of  an  appropriate  dietary.  An  excess  of  starchy  foods 
should  be  omitted  in  favour  of  partially  digested  cereals  and 
sugars,  and  with  this  object  toast  is  usually  preferable  to 
bread,  and  the  various  artificially  pancreatised  or  malted  foods 
to  oatmeal,  sago,  or  tapioca.  Potatoes  do  not  disagree,  at  any 
rate  during  the  earlier  stages  of  the  disease,  but  uncooked 
green  vegetables  and  fruits  are  apt  to  produce  flatulence. 
As  a  rule,  milk  is  easily  digested,  and  2  or  3  pints,  diluted 
if  necessary  with  lime-water,  may  be  given  during  the  course 
of  each  twenty-four  hours.  Cream,  on  the  other  hand,  is  dis- 
tasteful to  many  patients,  but  fresh  butter  is  often  digested  with- 
out apparent  difficulty.  The  increased  peptic  digestion  which 
is  apparent  in  so  many  cases  of  pancreatitis,  and  especially 
in  those  which  ensue  from  gall-stones,  compensates  to  a 
great  extent  for  the  deficiency  of  trypsin,  but  it  is  advisable 
to  select  those  varieties  of  animal  food  which  are  most  easily 
soluble  in  the  stomach.     Lightly  roast  or  grilled  beef  or  mut- 


440  CHRONIC   PANCREATITIS. 

ton  may  be  allowed  once  a  day,  while  pigeon,  chicken,  game, 
white  fish,  tripe,  and  sweetbreads  are  excellent  substitutes 
for  the  less  digestible  forms  of  butchers'  meat.  Veal,  pork, 
and  meat-fats  should  be  avoided,  and  ham  and  bacon  be 
tried  with  caution.  Eggs  are  very  apt  to  produce  nausea. 
In  all  cases  the  stools  should  be  carefully  watched,  and  if  they 
are  found  to  contain  an  excess  of  meat-fibre  the  diet  must  be 
readjusted.  Alcohol  in  any  form  is  apt  to  produce  acidity, 
but  sometimes  a  little  white  wine  diluted  with  soda  water 
appears  to  increase  the  appetite  without  disturbing  the  functions 
of  the  stomach.  The  "Nonal"  brands  of  ale  and  stout,  which 
are  practically  devoid  of  alcohol,  are  very  palatable  and  well 
worthy  of  trial.  Tea  is  apt  to  give  rise  to  acidity,  but  coffee 
with  milk  or  cocoa  made  from  the  nibs  or  husks  may  usually 
be  allowed. 

Medicinal. — The  chief  indications  for  medicinal  treatment 
are  the  maintenance  of  the  general  nutrition  and  the  control  of 
excessive  putrefaction  in  the  intestines.  In  view  of  the  partial 
suppression  of  the  pancreatic  functions,  it  is  always  advisable 
to  try  the  artificial  preparations  of  the  gland  either  in  the  form 
of  the  pancreatic  emulsion,  pancreatin,  the  glycerin  extract, 
or  the  keratin-coated  pill;  but  it  is  doubtful  whether  the  liquor 
pancreaticus  is  of  any  value  after  its  passage  through  the  stom- 
ach. The  various  preparations  of  malt  may  usually  be  em- 
ployed with  advantage,  either  alone  or  mixed  with  the  food,  or 
taka-diastase  may  be  prescribed  before  meals.  When  emacia- 
tion is  a  marked  feature  of  the  complaint,  cod-liver  oil  or  its 
emulsion  may  sometimes  be  given  with  success,  while  occasion- 
ally the  petroleum  emulsion  appears  to  favour  nutrition. 

When  pancreatitis  is  associated  with  a  stone  in  the  common 
bile-duct,  olive  oil  should  always  be  given  a  trial,  a  sherry- 
glassful  being  administered  each  morning  before  breakfast. 
Unfortunately,  however,  many  persons  find  the  treatment  very 
distasteful,  and  under  these  circumstances  it  should  be  omitted 
in  favour  of  the  eunatrol  pill  (4  grains),  two  or  more  of  which 


PRIMARY   DUODENITIS.  44 1 

may  be  given  before  each  meal,  or  of  the  oleate  of  sodium  (lo 
grains)  in  a  capsule  three  times  a  day  after  food.  Sometimes 
aspirin  may  be  advantageously  combined  with  the  oleate,  or  the 
pil.  cholehth  may  be  prescribed.  The  bowels  should  always 
be  carefully  regulated.  When  gastric  hyperacidity  is  present, 
a  saline  draught  before  breakfast  is  of  the  greatest  value,  but 
if  the  gastric  secretion  is  normal  or  subacidity  exists,  re- 
course should  be  had  to  the  confection  of  sulphur  and  guaiacum 
or  to  a  pill  containing  podophyllin,  creasote  and  rhubarb.  The 
treatment  of  symptoms  arising  from  secondary  intestinal  putre- 
faction should  be  carried  out  on  the  lines  already  laid  down 
for  the  management  of  chronic  intestinal  indigestion.  In  all 
cases  where  a  long  trial  of  medicinal  treatment  has  failed  to 
effect  a  cure,  it  is  advisable  to  consider  the  question  of  surgical 
interference. 

In  such  cases  Mayo  Robson  has  obtained  excellent  re- 
sults either  by  the  removal  of  the  gall-stones,  drainage  of  the 
gall-bladder,  or  by  the  performance  of  cholecystenterostomy, 
according  to  the  individual  necessities  of  the  case.  Trans- 
plantation of  the  ducts  has  also  been  undertaken  by  this  sur- 
geon with  success. 

3.  DUODENITIS. 

The  duodenum  is  apt  to  be  involved  by  any  inflammation 
which  affects  the  stomach  or  the  intestines,  but  it  is  doubtful 
whether  duodenitis  ever  occurs  as  an  independent  disease. 
From  the  point  of  view  of  etiology,  two  principlal  varieties, 
the  primary  and  the  secondary,  require  consideration. 

Primary  duodenitis  is  produced  by  the  same  conditions 
that  give  rise  to  acute  gastritis.  In  early  life,  exposure  to  cold 
or  wet  is  a  common  cause  of  the  complaint,  especially  when  the 
child  is  suffering  from  general  malnutrition.  In  other  instances 
an  excess  of  food  or  the  ingestion  of  substances  which  are  diffi- 
cult of  digestion  is  responsible  for  an  attack,  while  occasionally 
a  natural  idiosyncrasy  renders  some  article  of  diet,  which  is 


442  DUODENITIS. 

Otherwise  harmless,  injurious  to  the  alimentary  canal.  Acute 
gastro-duodenitis  frequently  ensues  from  the  use  of  decompos- 
ing meat,  fish,  vegetables  or  fruit  or  of  infected  milk  or  water, 
in  all  of  which  cases  either  ptomains,  toxalbumins,  or  patho- 
genic bacteria  find  direct  entrance  to  the  body  and  exert  their 
specific  deleterious  influence  upon  the  mucous  membrane  of 
the  digestive  tract. 

Occasionally  a  severe  and  destructive  inflammation  arises 
from  the  action  of  such  poisonous  substances  as  corrosive  acids 
and  alkalies,  metallic  salts  and  alkaloids,  or  acute  gastro- 
duodenitis  appears  in  the  form  of  an  epidemic  disease  of  which 
the  chief  symptom  is  jaundice. 

Duodenitis  of  secondary  origin  is  far  more  common  than 
the  primary  variety  and  is  a  constant  accompaniment  of  all 
diseases  of  the  stomach  attended  by  decomposition  of  food  or 
by  a  permanent  excess  of  free  hydrochloric  acid.  Local  dis- 
eases of  the  duodenum,  such  as  ulcer  and  cancer,  are  also 
associated  with  a  more  or  less  extensive  inflammation  of  its 
mucous  membrane,  and  a  similar  condition  often  ensues  from 
gall-stones,  hepatic  abscess,  cholangitis,  pancreatitis,  cancer  of 
the  pancreas  and  new  growths  or  tubercle  of  the  right  kidney. 
Chronic  toxaemias,  such  as  result  from  suppuration,  phthisis, 
nephritis,  retention  of  urine,  and  septicaemia  are  apt  to  be 
accompanied  by  gastroenteritis,  the  various  poisons  present 
in  the  circulation  being  partly  eliminated  by  the  mucous  mem- 
brane of  the  alimentary  tract.  Diseases  of  the  heart,  em- 
physema and  interstitial  pneumonia,  are  all  accompanied  by  a 
chronic  congestion  of  the  portal  system  which  predisposes  to 
inflammation  of  the  duodenum,  while  acute  pneumonia  and 
the  majority  of  the  acute  specific  fevers  are  liable  to  be  attended 
by  acute  gastro-duodenitis  during  their  febrile  stage. 

Symptoms. — The  general  symptoms  of  acute  duodenitis 
are  identical  with  those  of  acute  inflammation  of  the  stomach. 
The  onset  is  comparatively  abrupt  and  often  attended  by 
slight  shivering,  headache,  general  malaise,  and  pain  in  the 


SYMPTOMS.  443 

upper  part  of  the  abdomen.  Retching  and  vomiting  are 
almost  invariably  present,  and  may  persist  for  many  hours, 
the  ejecta  being  composed  of  alkaline,  bile-stained  mucus. 
Excessive  nausea  is  a  prominent  feature  in  many  cases  and 
there  is  a  pronounced  aversion  from  all  forms  of  food.  In  the 
primary  varieties,  and  especially  in  the  infective  form  of  the 
complaint,  the  temperature  of  the  body  rises  at  once  to  ioo°  to 
103°  F.,  and,  after  displaying  an  intermittent  character  for 
three  or  four  days,  gradually  falls  to  normal.  The  pulse  is 
usually  quick  and  feeble,  but  in  cases  of  toxic  poisoning  it  is 
sometimes  unduly  slow  or  intermittent.  The  tongue  is  covered 
with  a  creamy  fur,  the  breath  is  sweet  or  offensive,  and  herpes 
often  develops  upon  the  lips.  The  urine  is  scanty,  high-col- 
oured and  deposits  urates  on  standing.  Occasionally,  acute 
duodenitis  is  accompanied  by  a  paroxysmal  pain  in  the  abdo- 
men, localised  above  and  to  the  right  of  the  navel,  and  so  severe 
as  to  simulate  biliary  colic.  If  the  stomach  and  duodenum 
alone  are  affected  by  the  inflammation,  the  bowels  are  usually 
confined  and  the  stools  are  hard,  pale,  and  offensive;  but  if  the 
jejunum  is  implicated  a  peculiar  form  of  diarrhoea,  characterised 
by  the  evacuation  of  acid,  sour-smelling  brownish  or  gelatinous 
motions,  is  often  observed.  In  these  latter  cases  pain  in  the 
abdomen  and  an  action  of  the  bowels  often  occur  immediately 
food  is  introduced  into  the  stomach.  Inflammation  of  the 
large  intestine  is  attended  by  attacks  of  colic  and  by  liquid 
motions  containing  an  excess  of  mucus.  The  localising 
symptoms  of  duodenitis  depend  upon  an  inflammatory  obstruc- 
tion of  the  common  bile-duct.  This  phenomenon  is  by  no 
means  constant  even  in  severe  cases,  and  is  probably  more 
frequent  when  the  duct  opens  into  the  bowel  by  a  small  orifice 
than  at  the  summit  of  a  papilla. 

When  it  occurs,  the  skin  and  conjunctivae  become  jaun- 
diced on  the  third  or  fourth  day  and  the  urine  is  found  to  con- 
tain a  large  amount  of  bile. 

The  intensity  of  the  jaundice  varies  in  different  cases,  in 


444  DUODENITIS. 

some  being  very  slight  and  only  enduring  for  a  few  days,  while 
in  others  the  skin  presents  a  deep  saffron  hue  for  six  weeks  or 
longer.  In  the  more  persistent  cases  the  liver  is  uniformly 
enlarged,  smooth,  and  painless,  but  the  gall-bladder  can  seldom 
be  detected.  The  stools  are  white  and  offensive  and  may  be 
shown  to  contain  a  great  excess  of  fats  and  fatty  acids.  Al- 
though simple  duodenitis  always  terminates  by  recovery,  many 
persons  continue  to  suffer  from  flatulence,  nausea,  want  of 
appetite,  and  general  malaise  for  months  or  even  years  after 
an  attack  of  "catarrhal  jaundice,"  accompanied  in  many 
instances  by  sallowness  of  the  complexion,  mental  depression, 
lassitude,  irritability,  insomnia,  and  a  marked  disinclination  for 
fats  and  sweets.  The  bowels  are  sluggish  and  the  stools  paler 
and  more  offensive  than  in  health.  Examination  of  the  urine 
demonstrates  the  occasional  presence  of  bile  and  not  infre- 
quently the  pancreatic  reaction  may  be  detected.  These 
sequelae  are  far  more  common  than  might  be  supposed,  and  it 
is  by  no  means  unusual  for  a  patient  suffering  from  symptoms 
of  this  nature  to  ascribe  his  indigestion  or  "biliousness"  to  a 
former  attack  of  jaundice.  There  can  be  no  doubt  that  such 
symptoms  are  really  due  to  a  mild  form  of  pancreatitis,  which 
occurred  simultaneously  with  the  infection  of  the  common 
bile-duct,  but  did  not  subside  after  the  cure  of  the  duodenitis, 
while  the  occasional  existence  of  bile  in  the  circulation  sug- 
gests that  the]  ampulla  of  Vater  is  also  apt  to  remain  in  a 
state  of  incipient  inflammation. 

Recurrent  Acute  Duodenitis. — There  is  one  clinical 
variety  of  the  complaint  which,  owing  to  its  frequent  recurrence 
and  severe  symptoms,  deserves  special  recognition.  It  is 
usually  encountered  about  middle  age,  and  in  many '  cases 
there  exists  a  strong  family  predisposition  to  diabetes.  Several 
of  my  patients  had  previously  suffered  from  symptoms  suggest- 
ive of  gall-stones  and  possessed  an  enlarged  and  fatty  liver. 
Each  attack  exhibits  the  same  general  features.  After  exposure 
to  cold,  the  patient  is  seized  with  chilHness  or  actual  shivering, 


RECURRENT   ACUTE   DUODENITIS.  445 

the  epigastrium  becomes  distended  and  tender,  nausea,  flatu- 
lence, and  headache  ensue,  and  finally  vomiting  occurs.  The 
temperature  rises  abruptly  to  loi  to  103°  F.,  the  pulse  is  accel- 
erated, and  there  is  often  great  irritation  of  the  skin.  Within 
the  next  twelve  hours  severe  jaundice  develops  and  the  stools 
present  the  usual  white  appearance.  Abdominal  pain  in  the 
true  sense  of  the  word  is  never  experienced,  although  there  may 
be  considerable  discomfort  from  gaseous  distention  of  the  stom- 
ach and  intestines.  The  gall-bladder  is  rarely  palpable,  but 
there  is  often  tenderness  on  pressure  over  the  right  lobe  of  the 
liver  and  duodenum.  Each  attack  lasts  about  three  days,  at 
the  end  of  which  time  the  temperature  falls  and  the  icterus 
rapidly  diminishes.  Cases  of  this  description  are  usually 
regarded  as  examples  of  gall-stones,  and  the  absence  of  pain  is 
explained  by  the  passage  of  biliary  sand  rather  than  a  definite 
calculus.  A  little  consideration,  however,  will  usually  show 
that  the  mischief  is  really  situated  in  the  ampulla  of  Vater  and 
involves  the  pancreatic  as  well  as  the  common  bile-duct.  Ex- 
posure to  cold  plays  an  important  part  in  the  etiology  of  the 
disorder,  and  many  patients  invariably  suffer  from  an  attack 
if  they  sit  in  a  draught,  get  their  feet  wet,  or  loiter  about  in  a  cold 
wind.  True  pain  is  conspicuous  by  its  absence,  and  however 
severe  may  be  the  sensations  due  to  flatulent  distention,  the 
characteristic  phenomena  of  biliary  colic  are  never  observed. 
Again,  the  febrile  attack  is  quite  different  from  that  which 
attends  the  passage  of  a  stone  down  the  cystic  or  common 
bile-ducts,  while  the  absence  of  an  enlarged  and  tender  gall- 
bladder and  the  comparatively  short  duration  of  the  complaint 
negative  the  supposition  of  cholecystitis. 

The  fact  that  in  many  instances  the  urine  affords  the  pan- 
creatic reaction  suggests  that  the  duct  of  Wirsung,  as  well  as 
the  common  bile  duct,  suffers  from  inflammation  and  partial 
obstruction;  while  the  symptoms  of  disordered  digestion  so 
closely  resemble  those  of  acute  gastritis  that  the  coexistence 


446  ENTEROSPASM. 

of  this  disease  with  the  inflammation  of  the  duodenum  hardly 
admits  of  doubt. 

The  chief  difficulty  of  diagnosis  is  the  distinction  between 
acute  duodenitis  and  a  floating  stone  in  the  common  bile-duct, 
which  by  its  ball-valve  action  gives  rise  to  a  periodic  obstruc- 
tion to  the  flow  of  bile  and  consequent  febrile  jaundice.  In 
the  former  complaint,  however,  an  antecedent  attack  of  biliary 
coHc  can  rarely  be  ascertained  and  when  properly  treated  a 
cure  usually  results,  while  in  the  latter  the  patient  has  invari- 
ably suffered  from  typical  colic  and  a  cure  rarely  ensues  with- 
out resort  to  operation. 

Treatment. — The  treatment  of  inflammation  of  the  duode- 
num is  the  same  as  that  of  acute  gastritis  (Chapter  IV).  When 
the  patient  can  tolerate  olive  oil,  a  sherryglassful  each  morning 
before  breakfast  usually  removes  the  jaundice  within  ten  days 
and  often  prevents  secondary  pancreatitis.  In  cases  of  recur- 
rent duodenitis  exposure  to  cold  must  be  carefully  guarded 
against  and  indulgence  in  alcohol,  cream,  fruit,  and  strong 
tobacco  should  be  prohibited.  In  my  experience  the  most 
successful  treatment  is  the  daily  administration  of  a  sahne 
aperient  before  breakfast  combined  with  a  prolonged  course 
of  eunatrol  or  oleate  of  sodium  and  aspirin  after  meals. 

4.  ENTEROSPASM. 

This  complaint,  which  is  probably  a  mixed  sensory  and 
motor  neurosis  of  the  intestine,  is  of  considerable  practical 
importance,  since  it  is  extremely  apt  to  be  confounded  with 
other  painful  affections  of  the  abdominal  organs.  The  reality 
of  its  occurrence  has  been  proved  by  exploratory  operations 
undertaken  for  the  purpose  of  diagnosis,  when  portions  of  gut, 
varying  in  length  from  3  to  15  inches,  have  been  discovered 
pale,  empty,  and  rigidly  contracted,  but  quite  free  from  disease. 
When  the  spasm  disappears  the  intestine  is  observed  to  resume 
its  normal  colour  and  appearance  and  to  permit  the  passage  of 
gas  and  fluid  through  its  canal.     This  pecuHar  condition  may 


SYMPTOMS,  447 

affect  any  part  of  the  bowel  and  even  different  regions  at  the 
same  time,  but  it  is  most  frequent  in  the  large  intestine  and 
more  especially  in  the  ascending  colon  and  sigmoid  flexure. 

A  painful  spasm  of  the  wall  of  the  gut  may  be  induced  by 
almost  any  kind  of  local  irritation,  such  as  the  presence  of 
undigested  food,  slight  mechanical  obstruction,  a  foreign 
body,  or  acute  inflammation  of  its  tissues.  It  is  also  a  well- 
known  symptom  of  poisoning  by  lead,  copper,  and  other  chem- 
ical substances,  of  certain  diseases  of  the  nerves  and  spinal  cord, 
of  gout,  rheumatism,  diabetes,  and  purpura.  But  apart  from 
these  and  other  allied  conditions,  there  exists  an  important 
form  of  the  complaint  in  which  the  painful  spasm  appears  to 
be  chiefly  excited  by  a  psychical  disturbance  of  the  higher 
nervous  centres.  In  such  cases,  sudden  fright,  anxiety,  excite- 
ment, or  mental  exhaustion  is  followed  immediately  by  a  charac- 
teristic attack  which,  after  enduring  for  a  considerable  time, 
vanishes  almost  as  suddenly  as  it  appeared. 

A  careful  consideration  of  the  various  cases  which  have 
come  under  my  notice  has  convinced  me  that  there  exists  at 
least  two  clinical  forms  of  the  disease,  one  of  which  is  met  with 
in  children  and  tends  to  undergo  spontaneous  cure,  while  the 
other  constitutes  a  very  serious  and  intractable  complaint 
during  adult  life. 

The  Enterospasm  of  Childhood. — Out  of  fifty-seven 
examples  of  this  complaint  which  have  come  under  my  notice, 
forty-four  occurred  in  girls,  and  with  only  five  exceptions  the 
first  attack  developed  before  the  age  of  twelve  years.  In 
66  per  cent,  of  the  cases  one  of  the  parents  had  suffered  from 
phthisis.  Chronic  enlargement  of  the  tonsils  or  cervical  glands, 
otorrhoea,  or  anaemia  were  a  frequent  accompaniment  of  the 
digestive  disorder. 

S3rmptoms. — ^Paroxysmal  pain  in  the  abdomen  constitutes 
the  characteristic  feature  of  the  disease.  As  a  rule,  an  attack 
begins  about  midday  or  in  the  evening,  but  occasionally  it 
develops  during  the  night.     Its  onset  is  so  sudden  that  the 


448  ENTEROSPASM. 

child  may  be  cheerfully  playing  one  moment  and  screaming 
with  pain  a  few  minutes  later.  During  an  attack  the  face 
is  pale  and  drawn,  the  forehead  covered  with  sweat,  and  the 
pulse  small  and  quick,  while  in  some  instances  actual  collapse 
supervenes.  The  umbilical  region  is  the  part  of  the  abdomen 
to  which  the  pain  is  usually  referred,  although  not  infrequently 
the  ascending  or  descending  portions  of  the  colon  seem  to  be 
particularly  affected  or  the  sensation  slowly  passes  from  right  to 
left  across  the  belly.  The  pain  may  be  severe  from  its  com- 
mencement, but  it  usually  increases  in  intensity  until  a  maxi- 
mum is  reached,  after  which  it  gradually  subsides.  At  other 
times  it  disappears  as  suddenly  as  it  commenced  or  is  obviously 
relieved  by  the  expulsion  of  gas  from  the  bowel.  Some  patients 
invariably  vomit  when  the  pain  begins  and  may  continue  to 
retch  throughout  the  attack,  but  this  symptom  is  by  no  means 
invariable.  Its  duration  varies  from  five  minutes  to  several 
hours,  the  nocturnal  attacks  being  usually  the  most  prolonged. 
The  affected  region  of  the  abdomen  is  sometimes  rigid  and 
tender  on  pressure,  but  more  commonly  palpation  affords 
relief  and  the  child  will  often  press  its  fists  or  even  the  corner 
of  a  chair  into  the  abdomen  when  a  seizure  occurs.  There 
are  certain  conditions  which  appear  to  favour  or  even  to  excite 
an  attack.  Constipation  is  an  almost  invariable  accompani- 
ment of  the  disorder,  and  it  may  usually  be  noticed  that  the 
pain  is  aggravated  by  the  presence  of  an  overloaded  colon. 
In  some  cases  an  attack  will  occur  immediately  after  the 
ingestion  of  food  or  hot  liquids,  while  in  others  exhaustion 
from  want  of  nourishment  appears  to  excite  the  pain.  The 
habit  of  sending  children  to  bed  with  the  stomach  empty  is 
responsible  in  many  cases  for  a  nocturnal  attack.  Physical 
and  mental  fatigue  are  important  factors  in  the  causation  of 
the  symptom,  and  consequently  the  incidence  of  the  pain 
often  coincides  with  over-exercise  or  the  preparation  of  a 
laborious  task  for  school  on  the  following  day.  The  state  of 
the  appetite  varies  considerably,  but  it  is  usually  capricious 


TREATMENT.  449 

and  the  patient  exhibits  a  distaste  for  meat-fat,  eggs,  and 
certain  forms  of  sweets.  Sour  and  acid  substances,  on  the 
other  hand,  are  regarded  as  special  dainties,  and  both  lemons 
and  vinegar  are  taken  with  avidity.  Thirst  is  a  very  prominent 
symptom,  and  existed  in  63  per  cent,  of  my  cases.  The 
sensation  is  chiefly  experienced  at  night,  when  the  child  will 
often  rise  from  bed  and  drink  any  fluid  that  it  can  find. 
Constipation  is  present  in  more  than  three-quarters  of  the 
cases  and  increases  as  the  disease  progresses.  The  stools 
are  sometimes  hard,  pale,  and  foetid,  at  others  they  resemble 
putty  or  mortar,  while  occasionally  they  consist  of  scybala 
mixed  with  mucus.  In  about  one-quarter  of  the  cases,  dis- 
comfort ensues  immediately  after  meals  and  a  lienteric  form 
of  diarrhoea  is  observed,  the  stools  being  liquid  or  semisolid 
and  composed  of  undigested  food.  Some  children  invariably 
pass  a  motion  as  soon  as  an  attack  of  pain  comes  on,  but  the 
evacuation  never  exhibits  the  ribbon  or  pipe-stem  appearance 
that  is  met  with  in  the  adult  form  of  the  complaint. 

Although  there  may  be  no  actual  loss  of  flesh,  the  child 
remains  thin  and  anaemic  and  never  seems  to  improve  in  general 
health.  The  hands  and  feet  are  cold  and  blue  and  are  very 
liable  to  chilblains.  Aphthous  ulceration  of  the  tongue,  gums, 
or  palate  is  a  troublesome  complication  in  many  cases. 
After  the  age  of  puberty  the  various  symptoms  of  the  complaint 
usually  subside,  but  the  patient  may  be  subject  to  occasional 
attacks  of  gastritis  and  not  infrequently  develops  the  symptoms 
of  gastric  neurasthenia. 

Treatment. — Exposure  to  cold  must  be  carefully  avoided 
and  a  flannel  or  woollen  binder  should  be  worn  throughout 
the  year.  Tepid  baths  of  sea-water  are  useful  in  maintaining 
a  healthy  action  of  the  skin,  and  regular  but  not  excessive  ex- 
ercise in  the  open  air  should  be  encouraged.  A  bracing 
climate  is  most  suitable  for  these  cases. 

The  selection  of  an  appropriate  dietary  seldom  presents 
any  difficulty.  All  articles  of  food  which  contain  a  large 
29 


450  ENTEROSPASM. 

percentage  of  indigestible  material  must  be  avoided,  and 
hence  green  vegetables  and  fruits  should  be  prohibited. 
Condiments  and  highly  spiced  foods  must  also  be  forbidden 
on  account  of  their  stimulating  influence  upon  the  peristalsis 
of  the  stomach  and  intestines.  The  meals  should  be  given 
at  regular  intervals,  and  it  is  usually  advisable  to  administer 
bread  and  milk,  gruel,  tapioca,  or  other  light  food  about  half 
an  hour  before  the  child  retires  to  bed. 

The  most  prominent  indication  for  medicinal  treatment 
is  the  regulation  of  the  bowels.  As  a  rule,  a  mixture  of  the 
liquid  extract  of  cascara,  maltine,  and  glycerin  given  at  bed- 
time answers  best,  or  the  confection  of  senna  and  sulphur  may 
be  prescribed  in  appropriate  doses.  A  full  dose  of  castor  oil 
administered  immediately  the  pain  commences  seldom  fails 
to  cut  short  an  attack.  Drastic  and  saline  purgatives  often 
increase  the  tendency  to  pain.  When  the  bowels  act  immedi- 
ately after  meals,  sedatives  are  required  to  relieve  the  abnormal 
irritability  of  the  intestine,  and  with  this  object  a  small  dose 
of  nepenthe,  compound  tincture  of  camphor,  or  morphine, 
combined  with  aromatic  sulphuric  acid  should  be  given  twice 
a  day  before  food.  Occasionally  a  few  drops  of  tincture  of  nux 
vomica  and  dilute  nitric  acid  taken  before  meals  effects  a 
rapid  cure.  As  soon  as  the  bowels  have  been  brought  into  a 
satisfactory  condition,  an  attempt  should  be  made  to  cure  the 
anaemia  by  means  of  the  ammonio-citrate  or  tartrate  of  iron. 
When  the  attacks  of  pain  occur  frequently  a  few  minims  of 
the  tincture  of  belladonna  may  be  advantageously  combined 
with  the  iron  preparation. 

The  Enterospasm  of  Adults. — This  disorder  is  compara- 
tively rare  in  general  practice,  but  is  quite  familiar  to  the 
speciahst.  In  my  series  of  cases  it  constituted  nearly  8  per 
cent,  of  those  classified  as  intestinal  dyspepsias. 

Both  sexes  are  equally  affected,  but  it  rarely  develops 
before  twenty  years  of  age.  It  is  exceptionally  frequent  among 
artists,  musicians,  painters,  and  those  engaged  in  employments 


THE    ENTEROSPASM    OF    ADULTS.  45 1 

which  necessitate  severe  mental  effort.  Occasionally,  the 
tendency  to  it  appears  to  be  inherited,  and  in  a  large  propor- 
tion of  the  cases  one  of  the  parents  is  found  to  have  suffered 
from  neurasthenia,  migraine,  epilepsy,  or  asthma.  It  is  also 
relatively  frequent  in  families  that  possess  a  strong  liability 
to  tuberculosis.  Many  sufferers  from  the  complaint  refer  the 
first  attack  to  a  severe  accident,  fright,  an  acute  illness,  pro- 
longed mental  or  physical  strain,  to  the  ingestion  of  some  in- 
digestible substance,  or  to  the  abuse  of  purgatives;  but  it  also 
frequently  develops  without  apparent  cause  and  during  a 
period  of  perfect  health. 

As  a  rule,  the  attack  commences  quite  suddenly,  but  occa- 
sionally the  patient  is  warned  of  its  advent  by  some  particular 
symptom  which  he  has  learned  to  associate  with  it.  Thus, 
in  some  cases  the  pain  is  preceded  for  hours  or  even  days  by 
distention  of  the  abdomen,  oppression  at  the  chest,  an  irreg- 
ular action  of  the  heart,  asthma,  weariness,  or  vertigo,  while 
in  others  slight  shivering,  numbness  of  the  hands,  feet,  or  tongue 
or  discomfort  in  the  rectum  proves  an  invariable  herald  of  an 
attack.  The  pain  itself  is  usually  abrupt  in  onset  and  violent 
from  the  first;  but  occasionally  it  commences  by  a  sense  of  un- 
easiness in  one  part  of  the  abdomen  which  steadily  increases 
until  it  becomes  almost  intolerable.  Its  location  varies  in  dif- 
ferent cases,  and  even  during  the  course  of  a  single  attack  its 
maximum  intensity  may  shift  from  one  part  of  the  abdomen  to 
another.  Vomiting  is  an  inconstant  feature  and  the  tempera- 
ture is  never  elevated;  indeed,  when  the  pain  is  exceptionally 
violent  it  is  sometimes  accompanied  by  partial  collapse.  Dur- 
ing the  height  of  an  attack  the  patient  is  unable  to  stand  or 
even  to  sit  and  usually  lies  upon  his  back  with  the  knees  drawn 
up  and  the  hands  clasped  over  the  belly.  Micturition  may  be 
difficult  or  painful.  On  examination,  the  face  is  found  to  be 
pale  and  drawn,  the  pulse  quick  and  feeble,  the  surface  of  the 
body  cold,  and  the  forehead  covered  with  sweat.  The  abdom- 
inal wall  is  usually  rigid,  and  pressure  relieves  rather  than  in- 


452  ■   ENTEROSPASM. 

creases  the  suffering.  In  thin  individuals  the  contracted  colon 
may  sometimes  be  felt  as  a  hard  cord,  but  if  the  attack  has  al- 
ready persisted  for  several  hours,  gaseous  distention  of  the  sur- 
rounding coils  of  intestine  may  obscure  this  important  sign. 
The  finger  inserted  into  the  rectum  is  often  firmly  grasped  by 
the  contracted  bowel.  The  severe  attacks  rarely  persist  for 
more  than  twelve  hours,  but  the  milder  seizures  may  continue, 
with  occasional  remissions,  for  many  days  or  even  for  several 
weeks.  As  long  as  pain  exists,  the  appetite  remains  in  abey- 
ance and  food  produces  flatulence  and  discomfort,  but  thirst 
is  rarely  observed.  The  subjects  of  enterospasm  invariably 
suffer  from  obstinate  constipation,  and  during  an  attack  the 
stools  are  often  thin  and  ribbon-like,  owing  probably  to  con- 
comitant spasm  of  the  rectum.  When  the  disease  is  well  estab- 
lished, each  patient  usually  discovers  for  himself  the  condition 
which  most  frequently  excites  pain.  Thus,  in  some  instances 
physical  or  mental  fatigue  is  the  most  potent  factor  in  its  caus- 
ation, in  others  worry,  anxiety,  or  excitement,  while  not  infre- 
quently exposure  to  cold  or  merely  standing  for  a  time  on  a 
stone  pavement  or  damp  grass  is  invariably  followed  by  an 
attack.  Women  rarely  suffer  from  enterospasm  during  the 
later  months  of  pregnancy,  although  the  disease  is  apt  to  return 
immediately  after  delivery.  It  usually  ensues  after  a  physi- 
cal injury  or  a  surgical  operation.  The  attacks  recur  at 
irregular  intervals  which  vary  from  a  few  weeks  to  several 
years,  and  although  a  cure  is  sometimes  observed,  the  com- 
plaint often  persists  until  an  advanced  period  of  life. 

Diagnosis. — A  correct  diagnosis  of  enterospasm  may 
usually  be  made  by  careful  attention  to  the  history  of  the 
case  and  to  its  characteristic  clinical  features.  Unlike  other 
painful  diseases  of  the  abdomen,  an  attack  may  often  dejSnitely^ 
be  attributed  to  some  psychical  disturbance,  such  as  worry  or 
excitement.  The  pain  is  abrupt  in  onset,  violent  and  localised 
to  some  particular  region  of  the  abdomen,  especially  to  the  as- 
cending colon  or  sigmoid  flexure,  and  on  examination  the  af- 


DIAGNOSIS.  453 

fected  portion  of  the  bowel  may  be  felt  like  a  hard  and  some- 
what tender  cord.  In  bad  cases  collapse  with  a  subnormal 
temperature  may  exist,  and  there  is  usually  a  history  of  previous 
seizures  of  a  similar  character.  The  pain  often  disappears 
as  soon  as  the  bowels  have  been  evacuated  by  castor  oil. 

At  its  commencement  the  disease  may  easily  be  confused 
with  perforation  of  the  stomach  or  duodenum,  biliary,  renal, 
or  lead  coHc,  the  crises  of  tabes  dorsalis,  or  with  appendicitis. 
A  little  care,  however,  will  generally  suffice  to  exclude  these 
various  complaints,  while  a  history  of  previous  attacks  in  which 
the  pain  occupied  other  regions  of  the  abdomen  will  at  once 
suggest  the  possibility  of  the  intestinal  neurosis.  Chronic 
intussusception  in  the  adult  may  closely  simulate  enterospasm 
in  its  general  features,  but  the  constant  vomiting,  rapid  emacia- 
tion, excessive  tenderness,  persistent  tumour,  and  the  frequent 
existence  of  diarrhoea  in  the  former  disease  should  distinguish 
it  from  the  functional  disorder.  The  fact  that  so  many  suffer- 
ers from  enteropasm  exhibit  a  scar  over  the  region  of  their 
appendix  is  not  only  an  eloquent  testimony  to  the  frequency 
with  which  spasm  of  the  ascending  colon  is  confused  with 
inflammation  of  the  cascal  appendage,  but  also  serves  to  empha- 
sise the  uselessness  of  the  operation  as  a  curative  treatment  of 
the  disease.  The  sudden  onset  and  extraordinary  severity  of 
pain  unattended  by  fever  ought  to  negative  the  probability  of 
acute  inflammation,  while  the  absence  of  localised  tenderness, 
the  existence  of  a  cord-like  tumour,  and  the  peculiar  appearance 
of  the  stools  are  quite  opposed  to  the  theory  of  appendicitis. 
In  my  own  practice  I  have  seen  several  cases  of  chronic  duode- 
nal ulcer  which  had  been  mistaken  for  enterospasm,  on  account 
of  the  periodic  attacks  of  pain  with  comparative  freedom  from 
discomfort  in  the  intervals.  The  pain  of  duodenal  ulcer  is, 
however,  quite  distinct  from  that  of  the  intestinal  neurosis, 
since  it  usually  occurs  at  the  end  of  gastric  digestion,  is  relieved 
by  food  and  is  particularly  apt  to  occur  during  the  night.  Ex- 
amination will  also  show  the  existence  of  gastric  hypersecre- 


454  LITERATURE. 

tion  and  afford  other  important  evidence  of  ulcer    in   the 
vicinity  of  the  pylorus. 

Treatment. — This  is  usually  unsatisfactory  in  so  far  as  the 
cure  of  the  disease  is  concerned.  At  the  commencement  of  an 
attack  the  patient  should  go  to  bed,  hot  fomentations  should 
be  applied  to  the  abdomen  and  a  full  dose  of  castor  oil,  either 
with  or  without  tincture  of  opium,  be  administered.  As  soon 
as  the  bowels  have  been  thoroughly  evacuated,  the  pain  usually 
subsides.  Injections  of  morphine  often  prolong  an  attack. 
In  the  intervals  of  his  complaint,  the  patient  must  carefully 
avoid  exposure  to  cold,  overwork,  and  excitement.  Green 
vegetables  and  fruit  should  be  prohibited,  and  a  regular  daily 
action  of  the  bowels  be  secured  by  means  of  cascara  and  mal- 
tine  or  other  gentle  laxative.  A  prolonged  course  of  bella- 
donna and  valerianate  of  zinc  sometimes  appears  to  prevent  a 
recurrence  of  the  disease. 

LITERATURE. 

Disorders  of  Secretion. 

Boas.     Berl.  klin.  Wochenschr.,  1895,  looi. 

Bouveret.     Revue  de  Med.,  1892, 

Bouveret  et  Devic.  "La  Dyspepsia  par  Hypersecretion  Gastrique." 
Paris,  1902. 

Einhorn.     Medical  Record,  Nov.,  1895. 

Ewald.     Berl.  klin.  Wochenschr.,  1886,  825. 

Fenwick,  Soltau.  "  The  Clinical  Signij&cance  of  Gastric  Hypersecre- 
tion and  its  Connection  with  Latent  Disease  of  the  Appendix."  Proc, 
Royal  Soc.  Med.,  1910;  Lancet,  1910,  T.  706. 

Gluzinski  and  Jaworski.     Wien.  med.  Presse,  1882,  1601. 

Hayem.  Gaz.  hebdom.  de  med.  et  de  chir.,  Aug.,  1892;  AUgem.  Wien. 
med.  2^itung,  1894,  74. 

Honigmann.     Miinch.  med.  Wochenschr,  1887,  951. 

Jaworski.  Zeit.  f.  klin.  Med.,  xi,  2  and  3;  Wien.  med.  Presse,  1886, 
1681. 

Jiirgensen.     Deut.  Archiv.  f.  klin.  Med.,  xli,  569. 

Korczynski  and  Jaworski.     Deut.  Archiv.  f.  klin.  Med.,  xlvii,  578. 

Leyden.     Zeitschr.  f.  klin.  Med.,  1882,  605. 

Lyon.     "L' Analyse  du  sue  gastrique."     Th^se  de  Paris,  1880. 


LITERATURE.  455 

Marfan.     Gaz.  hebdom.,  1890,  xxxiii. 

Martius.     Deut.  med.  Wochenschr.,  xxxii,  638. 

Mathieu.     Archiv.  gen.  de  Med.,  1892;  Gaz.  des  hopit.,  1893,  Ixxi. 

V.  Noorden.     Charite  Annalen,  1890. 

Oestreich.     Wien.  klin.  Wochenschr.,  1895,  794, 

Osswald.     Miinch.  med.  Wochenschr.,  1894,  565. 

Pawlow.     "The  Work  of  the  Digestive  Glands."     Engl.  Trans.,  1906. 

Reichmann.     Berl.  klin.  Woch.,  1892,  727;  1884,  768;  1887,  199. 

Riegel.  Zeitschr.  f.  klin.  Med.,  xi,  167;  Miinch.  med.  Wochenschr., 
1884,  497;  Volkmann's  Samml.  klin.  Vortrage,  1886,  289. 

Rosenthal.   "  Ueber  nervose  Gastroxie."   Wien.  med.  Presse,  1886,  683. 

Rossbach.     Deut.  Archiv.  f.  klin.  Med.,  xxxv,  383. 

Sahli.     Correspondenzbl.  f.  Schweizer  Aerzte,  1885,  xv. 

Schreiber.  Deut.  med.  Wochenschr.,  1893,  692;  ibid.,  1894,  443. 
Archiv.  f.  Verdauungskrank.,  ii,  423. 

Sievers.     Finska  Lakaresall.  Handlingar,  1887,  xxix. 

Simitzky.     Berl.  klin.  Wochenschr.,  1901,  381.  . , 

Sticker.     Berl.  klin.  Wochenschr.,  1887,  768.  t    : 

Sticker  and  Hiibner.     Zeitschr.  f.  klin.  Med.,  xii,  114.  c 

Storch.     Deut.  klin.  Wochenschr.,  1889,  541. 

Strauss.     Zeitschr.  f.  klin.  Med.,  xxix,  221. 

v.  derVelden.    Volkmann's  Samml.  klin.  Vortrage  280. 

See  also  the  various  text-books  and  monographs  by  Brinton,  Wilson, 
Fox,  Prout,  Fenwick,  Ewald,  Boas,  Riegel,  Leube,  Debove  at  Rdmond, 
Penzoldt,  Lander  Brunton,  Fleiner,  Hemmeter,  Einhorn,  van  Valzah 
and  Nisbet,  Rosenheim,  Leo,  Martin,  Pick,  Mathieu,  Habershon;  and 
the  special  articles  in  the  various  dictionaries  and  cyclopaedias  of  medicine. 

Myasthenia. 

AUbutt.     Lancet,  1887,  ii,  814. 

Argaez.  "Essaisur  la  dilatation  adynamique  de  I'estomac."  Paris, 
1884. 

Aufrecht.     Centralbl.  f.  klin.  Med.,  1893,  153. 

Boas.     Deut.  med.  Wochenschr.,  1894,  576. 

Bouchard.     Gaz.  hebdom.  de  med.  et  de  chir.,  1884,  xxv. 

Bouveret  et  Devic.     Revue  de  med.,  1892,  i. 

Chomel.     "DesDyspepsies."     Paris,  1857. 

Dehio.     Verhandl.  des  VII.     Congress,  f.  inner.  Med.,  1888. 

Einhorn.     Berl.  klin.  Wochenschr.,  1891,  559. 

Fleiner.     Volkmann's  Sammlung  klin.  Vortrage,  ciii. 

Francon.     Lyon  Medicale,  Aug.,  1887. 


456  LITERATURE. 

Herschell.     "Indigestion,"  4th  Edit. 

Hoppe-Seyler.     Deut.  Archiv.  f.  klin.  Med.,  1,  82. 

Jaworski.     Wien.  klin.  Wochenschr.,  1888,  97. 

Kuhn.     Zeit.  f.  klin.  Med.,  xxvi,  572. 

Kiittner  and  Jacobson.     Berl.  klin.  Wochenschr.,  1892,  927. 

Leube.     Archiv.  f.  klin.  Med.,  xviii,  207. 

Malibran.  "Contribution  a  I'etude  des  ectasies  gastriques."  Paris, 
1885. 

Mascarel.     Bull.  gen.  de  therap.,  Feb.,  1887. 

Mintz.     Zeit.  f.  khn.  Med.,  xxv,  218. 

McNaught.     Brit.  Med.  Journ.,  1890,  i,  470. 

Naunyn.     Deut.  Archiv.  f.  klin.  Med.,  xxiii,  414. 

Oser.     Wiener  Klinik,  1881. 

Penzoldt.     "Die  Magenerweiterung."     Erlangen,  1875. 

Peter.     "De  la  dilatation  derestomac."     Gaz.  des  hop.,  1885. 

Reed,  Boardman.     Philad.  Med.  Journ.,  Feb.  5,  1900. 

Riegel.     Deut.  med.  Wochschr.,  1886,  929. 

Rockwell.     Boston  Medical  and  Surgical  Journal,  1892. 

Rosenbach.     Berl.  klin.  Wochenschr.,  1876,  li,  742. 

Rosenheim.     Archiv.  f.  Verdauungskrankh.,  ii. 

Schmidt.     Berl.  kHn.  Wochenschr.,  1886,  115. 

Schreiber.     Archiv.  f.  Verdauungskrank.,  ii,  423. 

Sievers  and  Ewald.     Therapeut.  Monats.,  Aug.,  1887. 

Ullman.     "Magenerweiterung."     1894. 

Thiebault.     "De  la  dilatation  de  I'estomac."     Paris,  1882. 

Wegele.     Miinch.  med.  Wochenschr.,  1894,  229. 

Winkhaus.  "Beitrag  zur  Lehre  von  der  Magenerweiterung." 
Dissert.,  Marburg,  1887. 

Inflammations  of  the  Stomach. 

Beaumont.  "Experiments  and  Observations  upon  the  Gastric  Juice 
and  the  Physiology  of  Digestion,"     Combe's  edition,  1833. 

Boas.  Centralblatt.  f.  klin.  Med.,  1895;  Miinch.  med.  Wochenschr., 
1887,  792. 

Cahn.     Berl.  kHn.  Wochenschr.,  1893,  565. 

Chantemesse.     Semaine  Medicale,  Nov.  13,  1889. 

Ebstein.     Virchow's  Archiv.,  Iv,  460. 

Eisenlohr.     Deut.  med.  Wochenschr.,  1892,  773. 

Ewald.     Berl.  khn.  Wochenschr.,  1886,  825. 

Fenwick,  Samuel.  "Morbid  States  of  the  Stomach  and  Duodenum," 
1866;  "Atrophy  of  the  Stomach,"  1880. 


LITERATURE.  457 

Fenwick,  Soltau.  "Disorders  of  Digestion  in  Childhood,"i897; 
Virchow's  Archiv.,  cviii,  87;  Trans.  Path.  Soc,  1894,  60;  Trans.  Clin. 
Soc,  xxvii,  6g. 

Fleiner.     Volkmann's  Samml.  klinischer  Vortrage,  1894,  103. 

Gaflfky.     Deut.  mad.  Wochenschr.,  1892,  112. 

Glax.     Deut.  med.  Zeit.,  1894,  492. 

Gluzinski.     Deut.  Archiv.  f.  klin.  Med.,  xxxix,  405. 

Gusmann.  Eine  Epidemic  von  acuter  Gastritis."  Wiirttemb. 
Correspondenzbl.,  1888. 

Hanot  and  Gombault.     Archiv.  de  Physiologic,  1882,  9. 

Hayem.  "Sur  I'anatomie  pathologique  de  la  gastrite  parenchyma- 
teusc  hyperpeptique,"     Paris,  1893;  Gaz.  hebdom.,  1892. 

Jaworski.  "Zur  Diagnose  des  atrophischen  Magenkatarrhs." 
Verhandl.  des  Congress,  f.  inn.  Med.,  Wiesbaden,  1888. 

V.  Kahlden.     Centralbl.  f.  klin.  Med.,  1887,  281. 

Klebs.     All.  Wiener,  med.  Zeitschr.,  1881. 

Kuester.     Deut.  Zeitschr.  f.  prak.  Med.,  xxxviii. 

Kundrat.  "Ueber  gastro-cntcritis  favosa."  Wien.  med.  Blatter, 
1884. 

Lesser.     "  Cirrhosis  ventriculi."     Inaug.  Dissert.,  Berlin,  1876. 

Leube.  Volkmann's  Samml.  klin.  Vortrage,  1873,  62;  Deut.  Archiv. 
f.  klin.  Med.,  xxiii,  901. 

Manassein.     Virchow's  Archiv.,  Iv,  413. 

Meyer.     Zeitschr.  f.  klin.  Med.,  xvi,  336. 

Nothnagel.     Deut.  Archiv.  f.  klin.  Med.,  xxiv,  353. 

Penzoldt.     Deut.  Archiv.  f.  kHn.  Med.,  H,  535. 

Riegel.     Nothnagel's  Cyclopaedia.     "Diseases  of  the  Stomach,"  p. 

459- 

Sachs.     Archiv.  f.  exper.  Patholog.  u.  Pharm.,  xxii. 

Schmidt.     Deut.  Archiv.  f.  klin.  Med.,  Ivii,  65. 

Smirnow.  "Ueber  gastritis  membranacca  und  diphtheritica." 
Virch.  Archiv.,  cxiii,  333. 

Sec.     Cliniquc  Physiol.,  Paris,  1881. 

Stienon.     Journ.  Brux.,  1888. 

Loesch.     AUgem.  Wien..  med.  Zeitung,  1881. 

Ueffelmann.     Deut.  Archiv.  f.  klin.  Med.,  xxvi,  431. 

Virchow.     Virchow's  Archiv.,  31,  388. 

Westphalen.     St.  Petersburg  Wochenschr.,  1891,  29. 

See  also  text-books  and  monographs  by  Debove  and  Remond,  Fleiner, 
Bamberger,  Birch-Hirschfeld,  Cohnheim,  Diijardin-Beaumetz,  Eichorst, 
Fleischer,  Henoch,  Lebert,  Leube,  Oser,  Strumpell  and  Zeigler. 


45^  LITERATURE. 

Nervous  Diseases. 

Alt.     Berlin,  klin.  Wochenschr.,  1888,  519. 

Boas.     Deut.  med.  Wochenschr.,  1889,  750. 

Bouchard.     Journ.  des  soc.  med.  de  Lille,  1883. 

Bouveret.     Rev.  de  med.,  1891. 

Bourneville  et  Seglas.     Archiv.  de  neurologic,  1883. 

Burkart.     "Zur  Pathologic  der  Neurasthenia  gastrica."     Bonn,  1882. 

Cahn.     Deut.  Archiv.  f.  klin.  Med.,  xxxv,  402. 

Charcot.     Gaz.  med.  de  Paris,  1889. 

Decker.     Miinch.  med.  Wochenschr.,  1892,  361. 

Dehio.     St.  Petersb.  med.  Wochenschr.,  1888,  i. 

Dumur.  "De  la  paralysie  du  cardia  ou  merycisme."  Th^se  de 
Berne,  1859. 

Einhorn.     "Rumination  in  Man."     Med.  Record,  1890. 

Fenwick,  Soltau.  "  Hyperaesthesia  of  the  Stomach."  Clin.  Journ., 
1905;  Trans.  Clin.  Soc,  xxxviii,  13. 

Glax.     Volkmann's  Samml.  klin.  Vortrage,  1882,  223. 

Glenard.     Lyon  med.,  1885,  xii-xviii. 

Hardy.     Gaz.  des  hopit.,  1881,  94. 

Herve  de  Lavour.  "De  la  Dyspepsie  nerveuse."  Th^e  de  Paris, 
1885. 

Jones.     Medical  News,  1894. 

Jurgensen.     Berlin,  klin.  Wochenschr.,  1888,  927. 

Koerner.     Deut.  Archiv.  f.  klin.  Med.,  xxxiii,  544. 

Kussmaul.    Volkmann's  Samml.  klin.  Vortrage,  1880,  181. 

Leube.     Deut.  Archiv.  f.  klin.  Med.,  xxiii,  98. 

Leube-Ewald.    Verhandl.  der  III.  Cong.  f.  inner.  Med.,  1884. 

Leyden.     Zeit.  f.  klin.  Med.,  1882,  298. 

Loewe.     Miinchen.  med.  Wochenschr.,  1892,  474. 

Luchsinger.     Archiv.  f.  gesamt.  Physiol.,  34. 

Mathieu.     Gaz.  hopitaux,  1888. 

Mitchell,  Weir.  "Die  Behandlung  gewisser  Formen  von  Neurasthe- 
nie  und  Hysteric."     Beriin,  1887. 

Miiller.     "  Han dbuch  der  Neurasthenic."     Paris,  1893. 

Poengscn.     Deut.  Archiv.  f.  khn.  Med.,  xxvi,  176. 

Rdmond.     Archiv.  gen.  de  med.,  1890. 

Richter.     Berl.  klin.  Wochenschr.,  1882,  195. 

Rosenthal.     Wien.  med.  Pressc,  1886,  683. 

Saupault.     "Les  dyspepsics  ncrvcuscs."     Paris,  1893. 

Schneider.     Heidelberg,  med.  Annalcn,  1846. 

SoUier.     Rdvue  dc  medicin,  1895. 


LITERATURE.  459 

Stiller.     "Die  nervosen  Magenkrankheiten."     Stuttgart,  1894. 
Sutherland.     "Air-suction  and  Eructation."     Lancet,  Aug.,  1896. 
Toussaint.     Archiv.  de  physiologic,  1875. 
Wiessner.     "Nervose  Dyspepsia."     Inaug.  Dissert.,  Berlin,  1888 

Dislocations  of  the  Stomach. 

Beyea.     Philad.  Med.  Journ.,  1893,  ii,  257. 

Bial.     Berlin,  klin.  Wochenschr.,  1896,  1107. 

Bier.     Deut.  Ztschr.  f.  Chirur.,  1900,  374. 

Bouveret.     "Maladies  de  restomac."     1893,  350. 

Chapotot.     "L'estomac  etle  corset."    Paris,  1891. 

Clozier.     Gaz.  des  hopit.,  1886. 

Coffey.    Philad.  Med.  Journ.,  Oct.  11,  1902. 

Davis.    Western  Medical  Review,  1897,  291. 

Duret.     Rev.  de  chirur.,  Paris,  1890,  430. 

Eve.     Brit.  Med.  Journ.,  1906,  i,  786. 

Ewald.     Berl.  klin.  Wochenschr.,  1890,  304. 

Fenwick,  Soltau.     Edinb.  Med.  Journ.,  1906,  ii,  396. 

Fer^ol.     Bull.  Soc.  m6d  des  hopit.,  1887. 

Glenard.  "Enteroptose  et  Neurasthenic."  Soc.  med.  des  hopit., 
1886. 

Kussmaul.     Samml.  klin.  Vortrage,  1880, 181. 

Litten.     Verhandl.  d.  VI.  Congr.  f.  inner.  Med.,  1887. 

Martius.     Verhandl.  d.  66.  Naturforscher.  Ver.     Samml.,  1894. 

Meinert.     Samml.  klin.  Vortrage,  1895,  115. 

Meltzing.     Ztschr.  f.  klin.  Med.,  xxvii,  193. 

Ricgel.  "Diseases  of  Stomach."  Nothnagel's  Practice  of  Medicine, 
p.  440. 

Stiller.     Archiv.  f.  Verdauungskrank,  ii,  3. 

Virchow.     Virchow's  Archiv.,  1853,  v. 

Weill.     Lyon  mddicale,  1890. 

Foreign  Bodies  and  Concretions. 

Baudamant.     Mem.  de  la  Soc.  Royale  de  Med.,  1777,  ii,  262. 

Best.     Brit.  Med.  Journ.,  1869,  ii,  630. 

BoUinger.     Miinchener  med.  Wochenschr.,  1891,  xxii,  383. 

Capelle.     Journ.  de  Med.  de  Bruxelles,  Feb.,  1861. 

Fenwick,  Soltau.     Cancer  and  Tumours  of  the  Stomach,  1902,  324. 

Finder.     Trans.  N.  Y.  Med.  Assoc,  1880. 

Friedlander,  C.     Berl.  klin.  Wochenschr.,  1881,  10. 

Gull,  Sir  W.     Trans.  Clinical  Soc,  iv,  183. 


46o  LITERATURE. 

Inman.     Medical  Times  and  Gazette,  1869,  ii,  6. 

Keiller.     Edin.  Monthly  Journal,  ist  series,  ix,  933. 

Kooyker.     Zeitschr.  f.  klin.  Med.,  1888,  xiv,  203. 

Langenbuch.  Verhandl.  der  deut.  Gesellschaft  f.  chir.,  IX.  Congr., 
1881,  54. 

Manasse.     Berl.  klin.  Wochenschr.,  1895,  723. 

May.     Brit.  Med.  Journ.,  1855,  ii,  1147. 

Paton.     Brit.  Med.  Journal,  1902,  i,  147. 

Pollock.     Trans.  Path.  Soc,  iii,  327, 

Prudden.    Proc.  N.  Y.  Path.  Soc,  1890,  32. 

Quain.     Trans.  Path.  Soc,  v,  145. 

Ritchie.     Edin.  Monthly  Journ.,  ist  series,  ix,  931. 

Russell.     Medical  Times  and  Gazette,  1869,  i,  681. 

Schonborn.  Berl.  klin.  Wochenschr.,  1883,  xvii,  260;  Archiv  f. 
Chirurg.,  1883,  xxix,  609. 

Schreiber.  Mittheil.  a.  d.  Grenzgebieten  d.  Medizin  u.  d.  Chirurg., 
1896,  i,  729. 

Schulten.  Mittheil.  aus  d.  Grenzgebieten  d.  Med.  u.  Chir.,  1897,  ii, 
289. 

Thornton.     Knowsley,  Trans.  Path.  Soc,  xxxv,  199. 

Tidemand.     Norsk.  Mag.  f.  Lagevidensk.,  1865,  80. 

Wood.     Medical  Facts  and  Observations,  1800,  viii,  139-146. 

Yeo.     Dubl.  Journ.  of  Med.  Sci.,  1873,  Ivi,  267. 

Larvae  and  Other  Living  Creatures  in  the  Stomach. 

AUoneau.     Journ.  compt.  du  diet,  de  Soc.  Med.,  Paris,  1829,  xxxiv, 

138. 

Ariel.     Cyclop.  Pract.  Medicine,  1835,  iv,  521. 

Berthold.  "Ueber  den  Aufenthalt  lebender  Amphibien  im  Men- 
schen."     Gottingen,  1850. 

Braun.     "Thierischen  Parasiten  des  Mensches."     Wurzburg,  1895. 

Cattle.     British  Medical  Journal,  1906,  ii,  77. 

Cayenne.     Ann.  de  la  med.  physiol.,  Paris,  1823,  iv,  136. 

Colin.     Journ.  de  m^d.  chir.  et  pharm.,  Paris,  1779,  460. 

Colter.     Medical  Times  and  Gazette,  1878,  i,  676. 

Dalton.     Amer.  Journ.  Med.  Sci.,  1865,  N.  S.,  xlix,  334. 

David.     Gaz.  med.  de  Paris,  1839,  vii,  491. 

Dickman.     Lancet,  1859,  ii,  337. 

Drew.     British  Medical  Journal,  1906,  ii,  1066. 

Dumas.     Gaz.  hebdom.  d.  Soc.  Med.  de  Montpelier,  1885,  vii,  571. 

Eyting.     Journ.  d.  prakt.  Heilk.,  1822,  liv,  16. 


LITERATURE.  461 

Fenwick,  Soltau.     Brit.  Med.  Journ.,  1910,  i,  371. 

Fermaud.     Journ.  de  med.  et  chirurg.  prat.,  1836,  vii,  57. 

Hope.     Trans,  Entomol.  Soc.  of  London,  1839,  256. 

Hutton.     "Encyclopaedia  Medica,"  vol.  viii,  211. 

Hie.     Wien.  med.  Blat.,  1882,  1108. 

Lallier.     "Etude  sur  la  myase."     Th^se  de  Paris,  1882. 

Luroth.     Gaz.  med.  de  Paris,  1839,  vii,  263. 

Mandt.     Dublin  Med.  Press,  1840,  iii,  p.  408. 

Marques.     Journ.  da  Soc.  Sc.  Med.  de  Lisbon,  1845,  xxii,  149. 

May.     British  Medical  Journal,  1906,  ii,  180. 

Pickells.  Trans.  College  of  Physicians  of  Ireland,  iv,  v;  Edinb.  Med. 
Journ.,  1846,  Ixvi,  382. 

Pinqualt.     Quart.  Journ.  Med.  Phys.  Soc,  Calcutta,  1839,  i,  291. 

Pout.     New.  Med.  and  Phys.  Journ.,  181 1,  ii,  449. 

Pruvot.  "Larves  dedipteres  trouvees  dans  le  corps  humain."  These 
de  Paris,  1882. 

Ranque.     Bull.  Fac.  de  Med.  de  Paris,  1806,  i,  143. 

Sander.     Wochenschr.  f.  d.  ges.  Heilk.,  1834,  iii,  617. 

Senator.     Berl.  klin.  Woch.,  1890,  xxvii,  141. 

Sentex.     Journ.  de  med.  de  Bordeaux,  1885,  xv,  196. 

Diseases  of  Other  Organs. 

Adler  and  Stern.     Zeit.  f.  klin.  Med.,  xviii,  46. 

Biernacki.     Centralbl.  f.  klin.  Med.,  1890,  265. 

Brieger.     Deut.  med.  Wochenschr.,  1889,  269. 

Cantani.     II  Morgagni,  1883. 

Edinger.     Berl.  klin.  Wochensch.,  1880,  117. 

Einhorn.     Berl.  klin.  Wochenschr.,  1889,  1042. 

Fenwick,  Samuel.     "Morbid  States  of  the  Stomach."     London,  1866. 

Fenwick,  Soltau.     Virchow's  Archiv,  cviii,  81. 

Ganz.     Verhandl.  d.  IX.  Cong.  f.  inner.  Med.,  1890. 

Griine.     Inaug.  Dissert.,  Giessen,  1890. 

Gluzinski.     Deut.  Archiv.  f.  klin.  Med.,  xxxix,  405. 

Hildebrandt.     Deut.  med.  Wochenschr.,  1889,  251. 

Honigmann.     Deut.  med.  Wochenschr.,  1890,  947. 

Hiifler.     Munch,  med.  Wochenschr.,  1889,  513. 

Immermann.     Verhandl.  des  VII.  Cong.  f.  inner.  Med.,  1889,  219. 

Klemperer.     Berl.  klin.  Wochenschr.,  1889,  526. 

Krawkow.     Inaug.  Dissert.,  St.  Petersburg,  1891. 

Manassein.     Virchow's  Archiv,  Iv,  413. 

V.  Noorden.     "Lehrb.  der  Pathologie  des  Stoflfwechsels,"  1893. 


462  LITERATURE. 

Osswald.     Munch,  med.  Wochenschr.,  1894,  565. 
Riegel.     Zeit.  f.  klin.  Med.,  xii,  167. 
Ritter  and  Hirsch.     Zeitsch.  f.  klin.  Med.,  xiii,  430. 
Rosenheim.     Berl.  klin.  Wochenschr.,  1890,  789. 
Rosenthal.     Berl.  klin.  Wochenschr.,  1888,  640. 
Sassezki.     St.  Petersb.  med.  Wochenschr.,  1859,  46. 

Intestinal  Indigestion. 

Boas.  "Diagnostik  u.  Therapie  der  Darmkrankheiten. "  Leipzig, 
1898. 

Bosanquet.     Lancet,  i,  1904. 

Cammidge.     "Arris  and  Gale  Lectures."     Lancet,  1904,  i,  782. 

Deaver.     Am.  Journ.  Med.  Sci.,  Feb.,  1903. 

Einhorn.  Am.  Journ.  Med.  Sci.,  Nov.,  1907;  Medical  Record,  Sept., 
1909. 

Fenwick,  Soltau.     Art.,  "Digestion."     AUbutt's  System  of  Medicine. 

Harley  and  Goodbody.  "Chemical  Investigation  of  Gastric  and 
Intestinal  Diseases."     1906. 

Hawkins.     Brit.  Med.  Journ.,  1906,  i,  65. 

Hemmeter.     "Diseases  of  the  Intestines."     1904. 

Korte.     "  Chir.  des  voies  biliares."  1905. 

Meyer.     Deut.  Arch.  f.  khn.  Med.,  1908,  45. 

v.  Noorden.  "Lehrbuch  der  Pathologie  des  Stoflfwechsels."  Berlin, 
1893. 

Opie.     "Diseases  of  the  Pancreas."     1903. 

Pawlow.     "The  Work  of  the  Digestive  Glands."     1904. 

Robson,  Mayo.     Lancet,  July,  1900;  ibid.,  March,  1904. 

Robson  and  Cammidge.     "The  Pancreas."     1907. 

Schmidt.  "Die Funktionspriifung  des  Darms  mittels  der Probekost." 
1904. 

Schmidt  and  Strasburger.     "Die  Faeces  des  Menschen."     1906. 

Senator.     Zeitsch.  f.  physiol.  Chemie,  iv,  1880. 

Strasburger.     Zeit.  f.  klin.  Med.,  1902,  413. 

Walker.     Med.  Chir.  Trans.,  1889,  257. 


INDEX. 


Abdomen,      inspection      of,      in 
chronic  hypersecretion,  74 
palpation  of,  in  chronic  hyper- 
secretion, 76 
tender    spots    on,    in    neuras- 
thenia gastrica,  224 
AchyHa  gastrica,  loi 

and  atrophic  gastritis,  differ- 
entiation, 208 
chemistry    of    digestion    in, 

103 
diagnosis,  104 
intestinal  form,  103 
symptoms,  102 
treatment,  104 
Acid  dyspepsia,  32,  57 

eructations   in  chronic  hyper- 
secretion, 69 
hydrochloric,  in  terminal  dys- 
pepsia of  phthisis,  378 
Acidity  in  hyperacidity,  39 

in  initial  dyspepsia  of  phthisis, 
372 
Amphibia  in  stomach,  dyspepsia 

due  to,  300 
Amylaceous  dyspepsia,  65 
Amyloid  degeneration  of  gastric 
mucosa  and  atrophic  gastritis, 
differentiation,  209 
Anachlorhydria,    loi.      See    also 

Achy  Ha  gastrica. 
Anacidity,  10 1.    See  also  Achylia 

gastrica. 
Anadeny  of  stomach,  199 
Anasmia,     dyspepsia     depending 
upon,  398,  399 
in    chronic  hypersecretion,   70 


Anemia    in   initial   dyspepsia  of 
phthisis,  373 
in  myasthenia  gastrica,  127 
pernicious,    atrophic    gastritis 
in,  202,  203 
Apoplexy    in    infantile    atrophy, 

330 
Appendicitis    in    chronic    hyper- 
secretion, 60,  61 
Appendix,    vermiform,     diseases 
of,  in    chronic   hypersecretion, 
60,  61 
Appetite  in  chronic  gastritis,  182 
gastroenteritis     of    infancy, 

326 
hypersecretion,  71 
in  hyperacidity,  39 
in  hypersesthesia  of    stomach, 

215 

in  initial  dyspepsia  of  phthisis, 

370 
in    myasthenia    gastrica,    118, 

125 

in  neurasthenia  gastrica,  222 
in      terminal      dyspepsia      of 
phthisis,  37  5 
Artificial  inflation  of  stomach  in 

gastroptosis,  264 
Asthenic    form    of    gastroptosis, 

262 
Asthma  dyspepticum,  120 
Ataxia,  locomotor,  gastric  crises 
of,  and  acute  hyper- 
secretion,   differen- 
tiation, 55 
and  hyperacidity,  dif- 
ferentiation, 45 


463 


464 


INDEX. 


Athrepsia,  304 
Atony  of  stomach,  106 
Atrophic  gastritis,  199 

and  achylia  gastrica,  differ- 
entiation, 208 

and  amyloid  degeneration  of 
gastric  mucosa,  differen- 
tiation, 209 

and  cancer  of  stomach, 
differentiation,  208 

chemistry  of  digestion  in, 
206 

diagnosis,  207 
differential,  207 

etiology,  200 

from  chronic  gastritis,  201, 
204 

from  corrosives,  205 

from  old  age,  202 

in  cancer  of  stomach,  201 

in  diseases  of  stomach  201 

in  gastroenteritis,  202 

in  pernicious  anaemia,  202, 
203 

pathology,  199 

prognosis,  207 

symptoms,  202 

treatment,  209 
general,  209 
Atrophy,  infantile,  304 

of      mucous      membrane      of 

stomach,    199.     See    also 

Atrophic  gastritis. 
Auscultatory-percussion    in   gas- 
troptosis,  264 


Baths,  hot-air,  in  hyperacidity, 

49 
Beetles  in  stomach,  290 
Bezoars   in   stomach,    dyspepsia 

due  to,  275 
Bibliography,  454 
Bile  in  intestinal  digestion,  411 

in  stomach  in  chronic  hyper- 
secretion, 77 


Biliary  colic  and  chronic  hyper- 
secretion,    differentiation, 
92 
and    hyperacidity,    differen- 
tiation, 44^ 
lithiasis   and    myasthenia  gas- 
trica, relation,  114 
Bilious  form  of  gastroptosis,  260 
Blood,  examination  of,  in  chronic 

gastroenteritis  of  infancy,  336 
Bowels.     See  Intestine. 
Brain,   diseases  of,  hyperacidity 
associated  with,  ^7, 
hemorrhage    of,     in    infantile 
atrophy,  319 
Breath  in  chronic  gastritis,  182 
Bronchial  glands,    enlarged   and 
caseous,  in  infantile  atrophy, 

319 
Bronchitis  in  infantile  atrophy, 

330 
Broncho-pneumonia  in  infantile 
atrophy,  319,  330 


Cammidge's  method  of  estimat- 
ing fat  in  faeces,  426 
pancreatic  reaction,  436 
Canine  hunger  in  chronic  hyper- 
secretion, 71 
Carbohydrates     in     faeces,     esti- 
mation of,  427 
Carcinoma  of  stomach  and  atro- 
phic gastritis,  differentia- 
tion, 208 
and  chronic  gastritis,  differ- 
entiation, 189 
hypersecretion,      differ- 
entiation, 90 
and    neurasthenia    gastrica, 

differentiation,  230 
atrophic  gastritis  in,  201 
in  chronic  hypersecretion,  86 
in  hypersecretion,  59,  60 
Catamenia  in  initial  dyspepsia  of 
phithsis,  373 


INDEX. 


465 


Catarrh  of  pharynx  in  infantile 
atrophy,  329 
of  stomach,  172 
Cerebral  sinuses,   thrombosis  of, 

in  infantile  atrophy,  319,  330 
Chemistry  of  digestion  in  achylia 
gastrica,  103 
in  atrophic  gastritis,  206 
in  chronic  gastroenteritis  in 

infancy,  334 
in  dyspepsia  from  syphilis, 

394 
of  old  age,  352 
in  initial  dyspepsia  of  phthi- 
sis, 373 
in     terminal     dyspepsia     of 
phthisis,  377 
Children,  enterospasm  of,  447 
Chill  of  stomach,  172 
Chlorides  in  urine,    decrease  in, 
in    chronic    hypersecretion,  73 
Chlorosis  associated  with  hyper- 
acidity, 33 
dyspepsia     depending     upon, 

398,  399 
Circulation  symptoms  in  myas- 
thenia gastrica,  127 
Clapotage    in    myasthenia    gas- 
trica, 120 
Classification  of  dyspepsia,  17,  22 
Climacteric,  dyspepsia  of,  304 
Climate  in  myasthenia  gastrica, 

138 
Coldness  in  chronic  gastritis,  184 
Coleoptera  in  stomach,  290 
Colic,  biliary,  and  chronic  hyper- 
secretion,    diflEerentiation, 
92 
and   hyperacidity,    differen- 
tiation, 44 
Colitis,  mucous,  in  neurasthenia 

gastrica,  229 
Colon,  inflammation  of,  in  chronic 
hypersecretion,  86 
neurosis  of,  and  gastric  hyper- 
£esthesia,  differentiation,  217 

30 


Concretions     in     stomach,     dys- 
pepsia due  to,  277,  284 
uratic,     in    infantile    atrophy, 

318 
Congestion  of  lungs  in  infantile 

atrophy,  300,  319 
Constipation  in  hyperacidity,  39 
treatment  of,  49 
in  initial  dyspepsia  of  phthisis, 

372 
in  myasthenia  gastrica,  118 
Continuous    secretion   of   gastric 

juice,  49 
Corrosives,       atrophic      gastritis 

from,  205 
Cough,  reflex,  in  initial  dyspepsia 
of  phthisis,  372 
stomach,   in   initial    dyspepsia 
of  phthisis,  372 
Crises,      gastric,      of     locomotor 
ataxia,      and      acute 
hypersecretion,      dif- 
ferentiation, 55 
and    hyperacidity,    dif- 
ferentiation, 45 
Cseri's     method     of     massaging 
abdomen,  135 

Degeneration,  amyloid,  of  gas- 
tric     mucosa,     and     atrophic 
gastritis,  differentiation,  209 
Diabetes     and     chronic     hyper- 
secretion, differentiation,  92 
complicating     chronic     hyper- 
secretion, 86 
dyspepsia      depending      upon, 

397 
Diarrhoea,  chronic  inflammatory, 

of  infancy,  304 
in  chronic  gastritis,  183 
in  chronic  hypersecretion,  67 
in  hyperacidity,  39 
in  myasthenia  gastrica,  127 
Diet  in  chronic  gastritis,  193 

gastroenteritis     of    infancy, 
344 


466 


INDEX. 


Diet  in  chronic  intestinal  indi- 
gestion, 428 
pancreatitis,  439 
in  gastroptosis,  272 
in  hyperacidity,  46 
in  myasthenia  gastrica,  138 
in  neurasthenia  gastrica,  234 
in  simple  acute  gastritis,  164 
Schmidt's,  for  examination  of 
faeces    in    chronic  intestinal 
indigestion,  424 
Digestion,      chemistry      of,      in 
achylia  gastrica,  103 
in  atrophic  gastritis,  206 
in  chronic  gastroenteritis  in 

infancy,  334 
in  dyspepsia  from  syphilis, 

394 
of  old  age,  3  54 
in  initial  dyspepsia  of  phthi- 
sis, 373 
in     terminal    dyspepsia     of 
phthisis,  377 
duodenal,  411 
effect    of     chronic    gastro-en- 

teritis  in  infancy  on,  331 
intestinal,  409 
bile  in,  411 

intestinal  juice  in,  413 
pancreatic  juice  in,  412 
products  of,   absorption   of, 
414 
leukocytosis  in  chronic  hyper- 
secretion, 71 
physiology  of,  in  chronic  hyper- 
secretion, 73 
Digestive  organs,  diseases  of,  in 
chronic  hypersecretion,    59 
tract,  inflammation   of,  in  in- 
fantile atrophy,  330 
Dilatation  of    stomach  and  gas- 
troptosis,    differentiation, 
268 
in  neurasthenia  gastrica,  228 
in  phthisis,  360 
Diptero  in  stomach,  288 


Disease  of  Reichmann,  49 
Displacements  of  stomach,  dys- 
pepsia due  to,  242 
total,    255.      See    also   Gas- 
troptosis. 
upward,   dyspepsia   due  to, 

243 
vertical,  angular  form,  246 
dyspepsia  due  to,  246 
fish-hook  variety,  247 
straight  variety,  247 
Distensibility  of  gastric  walls  in 

myasthenia  gastrica,  123 
Drugs,  dyspepsia  due  to,  407 
prolonged    use,    as    cause    of 
myasthenia  gastrica,  iii 
Duodenal  digestion,  411 
indigestion,  411 
ulcer    in    chronic    hypersecre- 
tion, 60,  61 
Duodenitis,  441 
primary,  441 
recurrent  acute,  444 
secondary,  442 
symptoms  of,  442 
treatment  of,  446 
Duodenum,  409 

intubation  of,  in  chronic  intes- 
tinal indigestion,  423 
Dyspepsia,  acid,  32,  57 
acute,  25 
amylaceous,  65 
chronic,  25 

classification  of,  17,  22 
depending  upon  anaemia,  398, 

399 
upon  chlorosis,  398,  399 
upon  diabetes,  397 
upon  diseases  of  heart,  379 
symptoms,  381 
treatment,  382 
of  kidneys,  383 
symptoms,  385 
treatment,  386 
of  liver,  382 
of  lungs,  3  59 


INDEX. 


467 


Dyspepsia  depending  upon  dis- 
eases of  other  organs,  359 
of  urinary  organs,  383 
symptoms,  385 
treatment,  386 
upon  drugs,  407 
upon  nervous  diseases,  400 
upon  phthisis,  360 
upon  pregnancy,  401 
etiology,  404 
flatulence  in,  402 
gastric  intolerance,  403 
treatment,  405 
vomiting  in,  403 
upon  specific  fevers,  387 
upon  syphilis,   389 

chemistry    of    digestion 

in,  394 
pain  in,  393 
symptoms,  392 
treatment,  396 
vomiting  in,  393 
differential  diagnosis  of  various 

forms,  24 
due  to  abnormalities  of  gastric 

secretion,  30 
due  to  amphibia  in  stomach, 

300 
due    to    bezoars    in    stomach, 

27s 
due    to    concretions   in   stom- 
ach, 277,  284 
due    to    displacements    of 

stomach,  242 
due  to  disturbance  of  nervous 
mechanism  of  stomach,  211 
due     to    failure    of    muscular 

power  of  stomach,  106 
due     to      foreign     bodies     in 
stomach,  275 
symptoms,  278 
treatment,  287 
due   to    gastroliths,    277,    284 

diagnosis,  285 
due  to  gastroptosis,  255.     See 
also  Gastroptosis. 


Dyspepsia    due    to  hair-balls  in 
stomach,  276,  278 
duration  and  complica- 
tions, 281 
physical  signs,  280 
due  to  inflammation  of  stomach, 

145 
due    to    insects    in    stomach, 
288 
symptoms,  294 
treatment,  298 
due  to  larva  in  stomach,  288 
symptoms,  294 
treatment,  298 
due    to    leeches    in    stomach, 

300 
due     to     living     creatures    in 

stomach,  287 
due    to    lizards    in    stomach, 

299 
due  to  slugs  in  stomach,  298 
due     to    snakes    in    stomach, 

302 
due    to     stones    in    stomach, 

277,  284 
due    to   upward   displacement 
of  stomach,  243 
physical  signs,  244 
symptoms,  244 
treatment,  245 
due   to  vegetable   tumours   in 

stomach,  283 
due    to   vertical  displacement 
of  stomach,  246 
causation,  248 
diagnosis,  253 
physical  signs,  252 
prognosis,  253 
symptoms,  250 
treatment,  254 
due     to    worms    in    stomach, 

300 
duodenal,  411 
flatulent,  65 

frequency   of     various    forms, 
23.  24 


468 


INDEX. 


Dyspepsia,  gastric,  21 
in  infancy,  303 
in  old  age,  303,  351 

chemistry  of  digestion  in, 
3  54 

pathology,  352 

symptoms,  354 

treatment,  356 
intestinal,    21,   408.      See  also 

Intestinal  indigestion. 
irritative,  57 
nervous,  21,  65,  220 
of  climacteric,  304 
of  phthisis,  3  60 
initial,  366 

acidity  in,  372 

anaemia  in,  373 

appetite  in,  370 

catamenia  in,  373 

chemistry  of  digestion  in, 

373 
constipation  in,  372 
course  of,  374 
existence       of       previous 

dyspepsia,  369 
flatulence  in,  372 
frequency  of,  366 
gastrectasis  in,  373 
influence  of  sex,  368 

of    type    of    lung    dis- 
ease, 368 
pain  in,  369 
reflex  cough  in,  372 
stomach  cough  in,  372 
symptoms  of,  369 
termination  of,  374 
tongue  in,  373 
vomiting  in,  370 
terminal,  374 
appetite  in,  375 
bowels  in,  377 
chemistry  of  digestion  in, 

377 
course  of,  378 
flatulence  in,  377 
hydrochloric  acid  in,  378 


Dyspepsia  of  phthisis,  terminal, 
nausea  in,  376 
pain  in,  376 
physical    examination  in, 

376 
symptoms  of,  375 
termination  of,  378 
thirst  in,  375 
tongue  in,  377 
treatment  of,  379 
vomiting  in,  376 
of  puberty,  303 
tobacco,  112 
varieties  of,  17,  20 
Dyspeptic  form  of  gastroptosis, 

259 
Dyspnoea  in  myasthenia  gastrica, 
120 

Effusion,  pleural,  in  infantile 
atrophy,  330 

Einhorn's  method  of  testing  activ- 
ity of  pancreatic  ferments,  423 

Electricity  in  chronic  gastritis,  193 
in  myasthenia  gastrica,  136 

Emaciation  in  chronic  gastritis, 

185 
in  myasthenia  gastrica,  126 
Endarteritis    of    stomach    from 

syphilis,  390 
Enterokinase,  413 
Enteroptosis   in   gastric   neuras- 
thenia, 228 
Enterospasm,  446 

and     chronic     hypersecretion, 

differentiation,  92 
of  adults,  450 
diagnosis,  452 
treatment,  454 
of  childhood,  447 
symptoms,  447 
treatment,  449 
Epigastric  discomfort  in  chronic 

gastritis,  179 
Erosion,   hasmorrhagic,   of  stom- 
ach, in  phthisis,  361 


INDEX. 


469 


Eructation,    nervous,    236.     See 
also  Nervous  eructation. 
acid,  in  chronic  hypersecretion, 

69 
gaseous,    in    myasthenia    gas- 
trica,  117 
Etat  mamelonne,  177,  361 
Extremities,   tonic  spasm  of,  in 
chronic  hypersecretion,  83 


F^CES,    carbohydrates    in,  esti- 
mation of,  427 
chemical    analysis,  in    chronic 

intestinal  indigestion,  425 
examination  of,  in  chronic  in- 
intestinal     indiges- 
tion, 424 
Schmidt's    diet     for, 
424 
fats    in,    Cammidge's    method 

of  estimating,  426 
in    chronic    gastroenteritis    of 

infancy,  321 
in    myasthenia    gastrica,     126 
nitrogen  in,  Kjeldahl's  method 
of  estimating,  425 
Fats  in  faeces,  Cammidge's  method 

of  estimating,  426 
Fatty   degeneration  of  heart   in 
infantile  atrophy,  319 
of  kidney  in  infantile  atrophy , 

317 
of  liver  in  infantile  atrophy, 

318 

Fermentation  in  chronic  hyper- 
secretion, 74 

Ferments,  pancreatic,  activity  of, 
Einhorn's   method   of  testing, 

423 
Fever  in  chronic  gastritis,  184 
gastroenteritis     of    infancy, 
326 
Fevers,    specific,    dyspepsia    de- 
pending upon,  387 
Fish-hook  stomach,  247 


Flatulence   in    chronic   gastritis, 
182 
hypersecretion,  69 
in  dyspepsia  due  to  pregnancy, 

402 
in  hyperacidity,  39 
in  initial  dyspepsia  of  phthisis, 

372 
in   terminal    dyspepsia    of 
phthisis,  377 
Flatulent  dyspepsia,  65 
Flesh,  loss  of,  in  chronic  gastro- 
enteritis of  infancy,  323 
Food  retention  in  chronic  hyper- 
secretion, 75 
in  myasthenia  gastrica,   124 
physical  signs,  128 
stagnation  in  myasthenia  gas- 
trica, 122 
Foreign    bodies    in    intestine    as 
cause  of  chronic  intestinal 
indigestion,  418 
in   stomach,    dyspepsia   due 
to,  275 

symptoms,  278 
treatment,  287 


Gall-stones  in   chronic   hyper- 
secretion, 60,  61 

Galvanisation     of     stomach     for 
hyperacidity,  49 

Gas,  eructation  of,  236.     See  also 
Nervous  eructation. 

Gaseous    eructations    in    myas- 
thenia gastrica,  117 

Gastralgia  and  hyperacidity,  dif- 
ferentiation, 44 

Gastrectasis    in    gastric    neuras- 
thenia, 228 
in  initial  dyspepsia  of  phthisis, 

373 
influence   of,    on    causation 
of     chronic    hypersecretion, 

58 
Gastric  dyspepsia,  21 


470 


INDEX. 


Gastric  crises  of  locomotor  ataxia 
and  acute  hypersecre- 
tion, differentiation,  5  5 
and  hyperacidity,  differ- 
entiation, 45 
fever,  158 

intolerance   due   to   dyspepsia 
of  pregnancy,  403 
in  chronic  hypersecretion,  78 
treatment,  97 
juice,  continuous  secretion  of, 

49 
neurasthenia,  21 
secretion,     dyspepsia    due    to 

abnormalities  of,  30 
tetany      in      chronic      hyper- 
secretion, 81 
Gastritis,  acute,  25,  145 
age-incidence,  145 
and     acute    hypersecretion, 

differentiation,  55 
clinical  varieties,  153 
etiology  of,  145 
age,  145 
sex,  145 
pathology  of,  1 52 
primary,  147 
secondary,  151 
sex-incidence,  145 
simple,  154 

and  acute  hypersecretion, 

differentiation,  161 
diagnosis  of,  160 

differential,  161 
diet  in,  164 
febrile  form,  158 
diagnosis,  162 
non-febrile     variety,     1 54 

diagnosis,  160 
prognosis  of,  162 
treatment  of,  163 
medicinal,  165 
toxic,  167 

diagnosis  of,  171 
pathology  of,  168 
symptoms  of,  169 


Gastritis,  acute,  toxic,  treatment 

of,  171 
atrophic,       199.         See      also 

Atrophic  gastritis. 
chronic,  172 

and  cancer  of  stomach,  dif- 
ferentiation, 189 
and    gastric    hypersesthesia, 

differentiation,  217 
and     myasthenia     gastrica, 

differentiation,  131,  190 
and    neurasthenia    gastrica, 

differentiation,  191,  231 
appetite  in,  182 
atrophic  gastritis  from,  201, 

204 
bowels  in,  183 
breath  in,  182 
coldness  in,  184 
course  of,  187 
diagnosis  of,  188 

differential,  189 
diarrhoea  in,  183 
diet  in,  193 
electricity  in,  193 
emaciation  in,  185 
epigastric  discomfort  in,  179 
etiology  of,  172 
fever  in,  184 
flatulence  in,  182 
from  syphilis,  391 
general  treatment,  igi 
hair  in,  184 
heart  in,  183 

lavage  of  stomach  in,  191 
medicinal  treatment,  195 
microscopic  appearances,  1 78 
mineral  waters  in,  195 
motor      insufficiency      of 

stomach  in,  187 
nausea  in,  180 
nervous  system  in,  183 
pathology  of,  177 
physical  examination  in,  185 
primary,  etiology  of,  173 
prognosis  of,  187 


INDEX. 


471 


Gastritis,  regurgitation  in,  182 
saliva  in,  183 
secondary,  etiology  of,  174 
skin  in,  184 
symptoms  of,  179 
thirst  in,  182 
tongue  in,  183 
treatment  of,  191 
diet,  193 
electricity,  193 
general,  191 
lavage  of  stomach,  191 
medicinal,  195 
mineral  waters,  195 
urine  in,  183 
vomiting  in,  180 
vomitus  matutinus  in,  181 
waterbrash  in,  182 
due  to  syphilis,  395 
infectious,  159 
primary  acute,  147 

chronic,  etiology  of,  173 
secondary  acute,  151 

chronic,  etiology  of,  1 74 
simple  acute,  154 
chronic,  and  chronic  hyper- 
secretion,    differentiation, 
92 
Gastrodiaphany  in  gastroptosis, 

26s 
Gastroenteritis,   atrophic  gastri- 
tis in,  202 
chronic,  of  infancy,  304 
apoplexy  in,  330 
appetite  in,  326 
bronchitis  in,  330 
broncho-pneumonia  in, 

319.  330 
catarrh  of  pharynx  in,  329 
chemistry  of  digestion  in, 

334 
complications,  329 
congestion    of     lungs    in, 

319.  330 
diagnosis,  341 
diet  in,  344 


Gastroenteritis,    chronic,    of    in- 
fancy, effects  of,  on  di- 
gestion in  adult  life,  331 
enlarged     and     caseous 
bronchial  glands 

in,  319 
mesenteric     glands 

in, 319 
etiology,  304 
examination  of  blood  in, 

336 
fatty       degeneration       of 
heart  in,  319 
of  kidney  in,  317 
of  liver  in,  318 
faeces  in,  321 
fever  in,  326 

haemorrhage  from  bowels 
in,  322 
of  brain  in,  319 
histological      appearances 
of    large    intestine 
in, 316 
of  small  intestine  in, 

315 
of  stomach  in,  311 
infectious  diseases  in,  331 
inflammation  of  digestive 

tract  in,  330 
loss  of  flesh  in,  323 
medicinal  treatment,  348 
miliary     tuberculosis     in, 

331 
morbid  anatomy,  308 

histology,  311 
nephritis  in,  317,  330 
nervous  system  in,  328 
oedema  of  lungs  in,  319 
pain  in,  323 
physical   examination   in, 

333 
pleural  effusion  in,  330 
prognosis,  339 
progress,  337 
pulmonary  tuberculosis  in, 

319 


472 


INDEX. 


Gastroenteritis,    chronic,    of    in- 
fancy, pulse  in,  328 
purulent  discharges  from 
nose,  ears,  or  vagina 

in,  331 
pericarditis  in,  330 
pyrexia  in,  326 
rickets  in,  331 
sequels,  329 
skin  in,  325 
symptoms,  320 
gastric,  321 
general,  323 
intestinal,  321 
termination,  337 
thirst  in,  327 

thrombosis   of   cerebral 
sinuses  in,  319,  330 
of  renal  veins  in,  317 
tongue  in,  327 
treatment,  342 
diet,  334 
general,  342 
medicinal,  348 
uratic  concretions  in,  318 
urine  in,  327 
vomiting  in,  322 
in  phthisis,  364 
Gastroliths,    dyspepsia    due    to, 
277,  284 
diagnosis,  285 
Gastroptosis,  255 

and  dilatation  of  stomach,  dif- 
ferentiation, 268 
and   myasthenia  gastrica,  dif- 
ferentiation, 131 
artificial  inflation  of    stomach 

in,  264 
asthenic  form,  262 
auscultatory -p ercussion  in, 

264 
bilious  form,  260 
compUcations  of,  266 
diagnosis  of,  267 
diet  in,  272 
dyspeptic  form,  2  59 


Gastroptosis,  etiology  of,  2  56 
frequency  of,  255 
gastrodiaphany  in,  265 
medicinal  treatment,  273 
physical  signs,  263 
prognosis  of,  269 
surgical  treatment,  271 
symptoms  of,  2  58 
treatment  of,  269 
diet  in,  272 
medicinal,  273 
surgical,  271 
Gastrosuccorrhoea,  49 
Gastroxie,  52 
Gastroxnysis,  52 

Glands,  bronchial,  enlarged  and 
caseous  in  infantile  atrophy, 

319 
mesenteric,  enlarged  and  case- 
ous, in  infantile  atrophy, 

319 
Gumma  of  stomach,  389  * 


Habitual  regurgitation,  239 
diagnosis,  240 
symptoms,  239 
treatment,  241 
Haemorrhage     from     bowels     in 
chronic  gastroenteritis  of  in- 
fancy, 322 
in  chronic  hypersecretion,  79 

treatment,  98 
of  brain  in  infantile  atrophy, 

319 
Haemorrhagic  erosion  of  stomach 

in  phthisis,  361 
Hair  in  chronic  gastritis,  184 
Hair-balls  in  stomach,  dyspepsia 
due  to,  276,  278 
duration  and  complica- 
tions, 281 
physical  signs,  280 
Headache,  violent,  25 

in   acute  hypersecretion,   52 
in  hyperacidity,  42 


INDEX. 


473 


Heart,     diseases     of,     dyspepsia 
depending    upon, 

379 
symptoms,  381 
treatment,  382 
fatty    degeneration    of,   in  in- 
fantile atrophy,  319 
in  chronic  gastritis,  183 
palpitation    of,  in  myasthenia 

gastrica,  120 
symptoms  in  myasthenia  gas- 
trica, 127 
Heredity  in  myasthenia  gastrica, 

107 
Hot-air  baths  in  hyperacidity,  49 
Hour-glass    stomach    in    chronic 

hypersecretion,  62 
Hunger,  canine,  in  chronic  hyper- 
secretion, 71 
pain  in  chronic  hypersecretion, 
64 
Hydrochloric    acid    in    terminal 

dyspepsia  of  phthisis,  378 
Hyperacidity,  30 
acidity  in,  39 

and    biliary   colic,    differentia- 
tion, 44 
and     chronic     hypersecretion, 

differentiation,  43,  90 
and  gastralgia,  differentiation, 

44 

and  gastric  crises  of  loco- 
motor ataxia,  differentia- 
tion, 45 

and  hyperassthesia  of  stom- 
ach, differentiation,  44 

and  ulcer  of  stomach,  differ- 
entiation, 43 

appetite  in,  39 

associated  with  chlorosis,  33 
with  chronic  hypersecretion, 

78 
with  diseases  of  brain,  33 
with  diseases  of  spinal  cord, 

33 
with  jaundice,  33 


Hyperacidity,    clinical    varieties, 

41 
constipation  in,  39 

treatment  of,  49 
diagnosis  of,  42 

differential,  43 
diarrhoea  in,  39 
diet  in,  46 
etiology  of,  3 1 

heredity,  34 

nervous  disorders,  32 

quality  of  food,  32 
flatulence  in,  39 
frequency  of,  30 
galvanisation  of  stomach  for 

49 
general  treatment,  45 
hot-air  baths  in,  49 
hypersecretion  complicating,42 
medicinal  treatment,  48 
migraine  in,  42 
nutrition  in,  39 
pain  in,  3  5 

causes  of,  37 
paroxysmal,  52 
physical  signs,  40 
prognosis,  42 
primary,  etiology  of,  31 
secondary,  33 
symptoms  of,  34 
treatment  of,  45 

diet,  46 

general,  45 

medicinal,  48 
tongue  in,  39 
violent  headache  in,  42 
vomiting  in,  39 
Hyperaesthesia   of   stomach,   211 

and    chronic    gastritis,    dif- 
ferentiation, 217 

and     gastric     ulcer,     differ- 
entiation, 216 

and      hyperacidity,      differ- 
entiation, 44 

and      neurosis      of      colon, 
differentiation,  217 


474 


INDEX. 


Hyperaesthesia   of    stomach,  ap- 
petite in,  215 

diagnosis,  216 
differential,  216 

diet  in,  218 

etiology,  212 

first  stage,  213 

fourth  stage,  215 

pain  in,  214 

physical  signs,  216 

second  stage,  214 

symptoms,  213 

third  stage,  214 

treatment,  218 
diet,  218 

vomiting  in,  214 
Hyperchloracidity,  30 
Hyperchlorhydria,  30 

in  myasthenia  gastrica,  124 
Hypersecretion,  19,  49 
acute,  25,  50 

and  acute  gastritis,  differen- 
tiation, 55 

and  gastric  crises  of  loco- 
motor ataxia,  differentia- 
tion, 55 

and  migraine,  differentia- 
tion. 55 

and  simple  acute  gastritis, 
differentiation,  161 

complicating  chronic  hy- 
persecretion, 68 

diagnosis  of,  54 
differential,  54 

duration  of  attack,  53 

etiology  of,  50 

jaundice  in,  54 

loss  of  weight  in,  53 

pain  in,  53 

sequels  of  attack,  54 

symptoms  of,  51 

tongue  in,  52 

treatment  of,  55 

between  attacks,  56 
during  attack,  55 

urine  in,  52 


Hypersecretion,     acute,     violent 
headache  in,  52 

vomiting  in,  51 
and  myasthenia  gastrica,  dif- 
ferentiation, 131 
complicating  hyperacidity,  42 
chronic,  56 

acid  eructations  in,  69 

acute    hypersecretion    com- 
plicating, 68 

anaemia  in,  70 

and   biliary    colic,    differen- 
tiation, 92 

and  carcinoma  of  stomach, 
differentiation,  90 

and     diabetes,     differentia- 
tion, 92 

and    enterospasm,    differen- 
tiation, 92 

and   hyperacidity,    differen- 
tiation, 43,  90 

and  simple  chronic  gastritis, 
differentiation,  92 

appendicitis  in,  60,  61 

appetite  in,  7 1 

before  a  meal,  63 

bile  in  stomach  in,  77 

bowels  in,  72 

canine  hunger  in,  7 1 

carcinoma    of    stomach    in, 
59,  60,  86 

character  of  vomit  in,  68 

complications  of,  78 
treatment,  97 

course  of,  87 

decrease  in  chlorides  in  urine 

in.  73 

of  sweat  in,  73 
diabetes  in,  86 
diagnosis  of,  89 

differential,  90 
diarrhoea  in,  67 
diet  in,  94 

digestion  leukocytosis  in,  7 1 
diseases  of  digestive  organs 
in,  59 


INDEX. 


475 


Hypersecretion,  chronic,  diseases 
of  vermiform  appendix 
in,  60,  61 
distention  of  stomach  in,  65 
duodenal  ulcer  in,  60,  61 
etiology  of,  56 
age,  63 

influence  of  gastrectasis,  58 
of    motor  insuflSciency, 

58 
sex,  63 
examination  of  stomach  in, 

74 
exploration     of     stomach 

with  tube  in,  76 
fermentation  in,  74 
flatulence  in,  69 
food  retention  in,  75 
frequency  of,  56 
gall-stones  in,  60,  61 
gastric  intolerance  in,  78 

treatment,  97 
general  treatment,  93 
hemorrhage  in,  79 

treatment,  98 
hour-glass  stomach  in,  62 
hunger  pain  in,  64 
hyperacidity  with,  78 
inflammation  of  colon  in,  86 
influence  of  gastrectasis  on 
causation  of,  58 

of  motor  insufficiency  on 
causation  of,  58 
inspection  of  abdomen  in,  74 
lavage  of  stomach  in,  75 
loss  of  flesh  in,  69 
medicinal  treatment,  96 
motor  power  of  stomach  in,  75 
nervous  phenomena  of,  82 
nocturnal  pain  in,  64 

vomiting  in,  67 
pain  in,  63 

palpation  of  abdomen  in,  76 
periodic  vomiting  in,  66 
perversions  of  taste  in,  71 
pharyngitis  in,  87 


Hypersecretion,    chronic,    physi- 
ology of  digestion  in,  73 

pulse  in,  73 

surgical  treatment,  99 

symptoms  of,  63 

termination  of,  87 

tetany  in,  81 
treatment,  99 

thirst  in,  71 

tongue  in,  71 

tonic    spasm  of    extremities 
in,  83 

treatment  of,  92 
complications,  97 
diet,  94 
general,  93 
medicinal,  96 
surgical,  99 

ulcer  of  stomach,  in,  59,  60, 
61,  80 

urea  in,  72 

urine  in,  72 

vomit  in,  character  of,  68 

vomiting  in,  66 
intermittent,  50 

acute,  78 
Hypoacidity,  loi.     See    also 

Achylia  gastrica. 
Hyposecretion,     10 1.     See     also 
Achylia  gastrica. 


Ileus,  nervous,  in  gastric  neuras- 
thenia, 227 
Indigestion.     See  Dyspepsia. 
Infancy,    chronic   gastroenteritis 
of,  304.     See  also  Gastro- 
enteritis,   chronic,    of    in- 
fancy. 
inflammatory   diarrhoea    of, 
304 
dyspepsia  in,  303 
Infantile  atrophy,  304 
Infectious    diseases    in    infantile 
atrophy,  331 
gastritis,  159 


476 


INDEX. 


Inflammation  of  colon  in  chronic 
hypersecretion,  86 
of      digestive      tract      in      in- 
fantile atrophy,  330 
of  intestine  as  cause  of  intes- 
tinal indigestion,  417 
of     stomach,     dyspepsia     due 
to,  145 
Inflammatory  diarrhoea,  chronic, 

of  infancy,  304 
Inflation,   artificial,   of  stomach, 

in  gastroptosis,  264 
Iniierited     tendency     to     myas- 
thenia gastrica,  107 
Insects    in    stomach,    dyspepsia 
due  to,  288 
sj'mptoms,  294 
treatment,  298 
Insomnia  in  rayasthenia  gastrica, 

125 
Intermittent  hj^ersecretion,  50 

acute,  78 
Intestinal  digestion,  409 
bile  in,  411 

intestinal  juice  in,  413 
pancreatic  juice  in,  412 
products  of,absorptionof,4 14 
dyspepsia,    21,    408.     See  also 

Intestinal  indigestion. 
form  of  achylia  gastrica,    103 
functions  in   myasthenia   gas- 
trica, 126 
indigestion,  408 
chronic,  417 

Cammidge's     method     of 
estimating  fat  in  faeces 
in,  426 
chemical  analysis  of  faeces 

in,  42  5 
diet  in,  428 
diseases   of   other    viscera 

as  cause,  418 
disorders  of  secretions  as 

cause,  417 
estimation     of     carbohy- 
drates in  fasces  in,  427 


Intestinal    indigestion,    chronic, 
etiology  of,  417 

examination   of  fseces  in, 
424 
Schmidt's     diet     for, 
424 

foreign  bodies  in  intes- 
tine as  cause,  418 

inflammation  of  intestine 
as  cause,  417 

intubation  of  duodenum 
in,  423 

Kjeldahl's  method  of 
estimating  nitrogen  in 
faeces  in,  425 

medicinal  treatment,  429 

myasthenia  of  intestine 
as  cause,  418 

nervous  disorders  of  in- 
testine as  cause,  418 

physical  signs,  422 

symptoms  of,  419 

treatment  of,  428 
diet,  428 
medicinal,  429 
juice    in    intestinal    digestion, 

413 

myasthenia  as  cause  of  chronic 
intestinal  indigestion,  418 
Intestine,  disorders  of  secretions, 
as    cause    of    intestinal   in- 
digestion, 417 

foreign  bodies  in,  as  cause  of 
chronic  intestinal  indi- 
gestion, 418 

haemorrhage  from,  in  chronic 
gastroenteritis  of  p r e g - 
nancy,  322 

in  chronic  gastritis,  183 
hypersecretion,  72 

in  terminal  dyspepsia  of 
phthisis,  377 

inflammation  of,  as  cause  of 
intestinal  indigestion,  417 

large,  histological  appearances, 
in  infantile  atrophy,  316 


INDEX. 


477 


Intestine,    nervous   disorders   of, 
as  cause  of  chronic  intestinal 
indigestion,  418 
small,       histological      appear- 
ances,  in   infantile  atrophy, 

315 

Intubation  of  duodenum  in 
chronic  intestinal  indi- 
gestion, 423 

lodipin  in  testing  motor  insufB- 
ciency  of  stomach,  123 

Irritative  dyspepsia,  57 

Jaundice  associated  with  hyper- 
acidity, S3 
in  acute  hypersecretion,   54 

Kidneys,  diseases  of,  dyspepsia 
depending  upon,  383 
symptoms,  385 
treatment,  386 
fatty     degeneration     of,     in 
infantile  atrophy,  317 
Kjeldahl's  method  of  estimating 
nitrogen  in  fsces,  425 

Larva  in  stomach,  dyspepsia  due 
to,  288 
symptoms,  294 
treatment,  298 
Lavage    of    stomach    in    chronic 
gastritis,  191 
hypersecretion,  75 
in  myasthenia  gastrica,  136 
Leeches   in    stomach,    dyspepsia 

due  to,  300 
Lepidoptera  in  stomach,  291 
L'estomac  k  cellules,  177 
Leube's  test  meal  for  motor  in- 
sufficiency of  stomach,  122 
Leukocytosis,      digestion,     in 

chronic  hypersecretion,  71 
Literature,  454 

Lithiasis,  bihary,  and  myasthenia 
gastrica,  relation,  114 


Liver,     diseases     of,     dyspepsia 
depending  upon,  382 
fatty    degeneration    of,  in    in- 
fantile atrophy,  318 
symptoms    in    myasthenia 
gastrica,  127 
Living     creatures     in     stomach, 

dyspepsia  due  to,  287 
Lizards    in    stomach,    dyspepsia 

due  to,  299 
Locomotor  ataxia,  gastric  crises 
of,  and  acute  hyper- 
secretion, differentia- 
tion, 55 
and  hyperacidity,  differ- 
entiation, 45 
Lungs,  congestion  of,  in  infantile 
atrophy,  319,  330 
diseases  of,  dyspepsia  depend- 
ent upon,  359 
oedema     of,    in    infantile 
atrophy,  319 

Mamillation     of     stomach     in 

phthisis,  361 
Marasmus,  304 
Massage  in  myasthenia  gastrica, 

134 
Mesenteric  glands,  enlarged  and 
caseous,    in   infantile  atrophy, 

319 
Migraine,  25 

and  acute  hypersecretion, 

differentiation,  55 
in   hyperacidity,  42 
Miliary  tuberculosis  in  infantile 

atrophy,  331 
Mineral   waters   in    chronic    gas- 
tritis, 195 
in  myasthenia  gastrica,  138 
Motor  insufficiency  of  stomach, 
106 
in    chronic    gastritis,    187 
influence    of,     on    causa- 
tion of    chronic  hyper- 
secretion, 58 


478 


INDEX. 


Motor  insufiBciency  of  stomach, 
iodipin  test  for,  123 
Leube's  test  meal  for,  122 
salolin  testing,  122,  123 
power  of  stomach  in   chronic 
hypersecretion,  75 
Mucous    colitis    in    neurasthenia 
gastrica,  229 
membrane  of    stomach,   amy- 
loid   degeneration,    and 
atrophic  gastritis, 
diflFerentiation,  209 
atrophy  of,  199.     See  also 
Atrophic  gastritis. 
Muscular     power     of     stomach, 
dyspepsia  due  to  failure  of,  106 
Myasthenia  gastrica,  106 
acute,  115 

age-incidence,  106,  107 
anasmia  in,  127 
and     biUary    lithiasis,   rela- 
tion, 114 
and  chronic  gastritis,  differ- 
entiation, 131,  190 
and  gastroptosis,  diflFerentia- 
tion, 131 
and    hypersecretion,    differ- 
entiation, 131 
and    neurasthenia    gastrica, 

differentiation,  130 
and  pyloric  stenosis,  differ- 
entiation, 132 
antiseptic  treatment,  140 
appetite  in,  118,  125 
chemical  analysis  of  stomach 

contents  in,  129 
circulation  symptoms,  127 
clapotage  in,  120 
climate  in,  138 
constipation  in,  118 
diagnosis,  130 

differential,  130 
diarrhoea  in,  127 
diet  in,  138 

discomfort  during  digestion 
in,  116 


Myasthenia   gastrica,  diseases  of 

skin  in,  127 
dyspncea  in,  120 
electricity  in,  136 
emaciation  in,  126 
etiology,  108 

prolonged  use  of  drugs,  1 1 1 

smoking,  iii 

strong  tea,  109 
faeces  in,  126 
food  retention  in,  124 

physical  signs,  128 
frequency,  106 
gaseous  eructations  in,  117 
general  health  in,  119 
heart  symptoms,  127 
heredity-incidence,  107 
hyperchlorhydria  in,  124 
inherited  tendency  to,  107 
insomnia  in,  125 
intestinal  functions  in,  126 
latent    stage,  symptoms    of, 

IIS 
lavage  of  stomach  in,  136 
liver  symptoms  in,  127 
massage  in,  134 
medicinal  treatment,  140 
mineral  waters  in,  138 
nausea  in,  126 
nervous  symptoms,  128 
pain  in,  119 

palpitation  of  heart  in,  120 
physical  signs,  120 
primary,  etiology  of,  108 
prognosis,  132 
prolonged   use   of   drugs   as 

cause.  III 
pulse  in,  119 
Salisbury  treatment,  140 
secondary,  etiology  of,  113 
sex-incidence,  106,  107 
smoking  as  cause,  iii 
splashing  sounds  in,  120 
stage  of  food  stagnation,  116 
stagnation    of    gastric    con- 
tents in,  122 


INDEX. 


479 


Myasthenia  gastrica,  strong  tea 

as  cause,  109 
symptoms,  114 

latent  stage,  115 

stage  of  food  stagnation, 
116 
thirst  in,  118 
tongue  in,  119 
treatment  of,  133 

antiseptic,  140 

climate,  138 

diet,  138 

electricity,  136 

general  measures,  134 

lavage,  136 

massage,  134 

medicinal,  140 

mineral  waters,  138 

prophylaxis,  133 

Salisbury,  140 
Turck's  internal  masseur  in, 

137 
needle-douche  in,  137 
undue  distensibility  of  gas- 
tric walls  in,  123 
urine  in,  120,  127 
vomiting  in,  118,  126 
water-test  for,  129 
intestinal,  as  cause  of  chronic 
intestinal  indigestion,  418 
Myiasis,  288 


Nausea  in  chronic  gastritis,  180 
in  myasthenia  gastrica,  126 
in      terminal      dyspepsia      of 
phthisis,  376 

Needle-douche,  Turck's,  in  myas- 
thenia gastrica,  137 

Nephritis    in    infantile    atrophy, 

317,  330 
Nervous  diseases,  dyspepsia  de- 
pending upon,  400 

disorders  of  intestine  as  cause 
of  chronic  intestinal  indi- 
gestion, 418 


Nervous  dyspepsia,  21,  65,  220 
eructation,  236 

etiology,  236,  237 

symptoms,  236 

treatment,  238 
ileus  in  neurasthenia  gastrica, 

227 
mechanism    of    stomach,   dys- 
pepsia   due    to    disturbance 

of,  211 
phenomena  in  myasthenia  gas- 
trica, 128 

of  chronic  hypersecretion,  82 
system     in    chronic     gastritis, 
183 
gastroenteritis  of  infancy, 
328 
Neurasthenia  gastrica,  21,  220 

and  cancer  of  stomach,  dif- 
ferentiation, 230 

and  chronic  gastritis,  differ- 
entiation, 191,  231 

and  myasthenia  gastrica,  dif- 
ferentiation, 130 

and  ulcer  of  stomach,  differ- 
entiation, 231 

appetite  in,  222 

complications,  228 

diagnosis,  230 
differential,  230 

diet  in,  234 

dilatation    of    stomach    in, 
228 

enteroptosis  in,  228 

etiology,  220 

gastrectasis  in,  228 

medicinal  treatment,  234 

mild  form,  222 

mucous  colitis  in,  229 

nervous  ileus  in,  227 

prognosis,  229 

severe  form,  225 

symptoms,  221 

tender  spots  on  abdomen 
in,  224 

treatment,  232 


48o 


INDEX. 


Neurasthenia     gastrica,      treat- 
ment, diet,  234 
general,  232 
medicinal,  234 
Neurosis    of    colon    and    gastric 
hypersesthesia,    differentiation, 
217 
Night    pain    in    chronic    hyper- 
secretion, 64 
vomiting    in    chronic     hyper- 
secretion, 67 
Nitrogen    in    fseces,     Kjeldahl's 

method  of  estimating,  425 
Nocturnal  pain  in  chronic  hyper- 
secretion, 64 
vomiting    in    chronic     hyper- 
secretion, 67 
Nutrition  in  hyperacidity,  39 


CEdema     of    lungs    in    infantile 

atrophy,  319 
Old  age,  dyspepsia  in,  303,  351 

See  also  Dyspepsia  in  old  age. 


Pain,  hunger,  in  chronic  hyper- 
secretion, 64 

in  acute  hypersecretion,  53 

in    chronic    gastroenteritis    of 
infancy,  323 
hypersecretion,  63 

in  dyspepsia  from  syphilis,  393 

in  hyperacidity,  3  5 
causes  of,  37 

in  hyperaesthesia  of    stomach, 
214 

in  initial  dyspepsia  of  phthisis, 

369 
in  myasthenia  gastrica,  119 
in    terminal    dyspepsia    of 

phthisis,  376 
nocturnal,    in    chronic    hyper- 
secretion, 64 
Palpation  of  abdomen  in  chronic 
hypersecretion,  76 


Palpation  of  heart  in  myasthe- 
nia gastrica,  120 

Pancreatic  ferments,  activity  of, 
Einhorn's  method  of  testing, 

423 
juice    in    intestinal    digestion, 

412 
reaction  of  Cammidge,  436 
Pancreatitis,  chronic,  431 

Cammidge' s  reaction  in,  438 
diagnosis  of,  438 
diet  in,  439 
etiology  of,  431 
medicinal  treatment,  440 
physical  signs,  435 
prognosis  of,  438 
symptoms  of,  433 
treatment  of,  diet,  439 
medicinal,  440 
Paroxysmal  hyperacidity,  52 
Percussion,  auscultatory,  in  gas- 

troptosis,  264 
Pericarditis,  purulent,  in  infantile 

atrophy,  330 
Pernicious  anaemia,  atrophic  gas- 
tritis in,  202,  203 
vomiting  in  pregnancy,  403 
Pharyngitis    in    chronic    hyper- 
secretion, 87 
Pharynx,  catarrh  of,  in  infantile 

atrophy,  329 
Phosphates  in   urine  in   chronic 

hypersecretion,  72 
Phthisis,    dilatation   of   stomach 
in,  360 
dyspepsia  dependent  upon,  360 
dyspepsia   of,    360.      See   also 

Dyspepsia  of  phthisis. 
gastroenteritis  in,  364 
haemorrhagic  erosion  of  stom- 
ach in,  361 
in  infantile  atrophy,  319 
mamillation  of  stomach  in,  361 
morbid  state  of  stomach  in,  360 
ulceration  of  stomach  in,  361 
ventriculi,  199 


INDEX, 


481 


Pleural  efifusion  in  infantile  atro- 
phy, 330 
Pregnancy,  dyspepsia  depending 
upon,  401.    See  also  Dyspepsia. 
Puberty,  dyspepsia  of,  303 
Pulmonary     tuberculosis.         See 

Phthisis. 
Pulse   in    chronic   gastroenteritis 
of  infancy,  328 
hypersecretion,  73 
in  myasthenia  gastrica,  119 
Purulent   discharges   from    nose, 
ears,  or  vagina  in  infantile 
atrophy,  331 
pericarditis  in  infantile  atrophy, 

330 
Pyloric  stenosis  and  myasthenia 

gastrica,  differentiation,  132 
Pyrexia  in  chronic  gastroenteritis 

of  infancy,  326 

Reflex  cough  in  initial  dyspepsia 

of  phthisis,  372 
Reichmann's  disease,  49 
Renal    veins,    thrombosis   of,    in 

infantile  atrophy,  317 
Regurgitation,  habitual,  239 
diagnosis  of,  240 
symptoms  of,  239 
treatment  of,  241 
in  chronic  gastritis,  182 
Rickets  in  infantile  atrophy,  331 

Salisbury  treatment  of  myas- 
thenia gastrica,  140 

Saliva  in  chronic  gastritis,  183 

Salol  in  testing  motor  insuffi- 
ciency of  stomach,  122,  123 

Schmidt's  diet  for  examination 
of  faeces  in  chronic  intestinal 
indigestion,  424 

Secretion,  continuous,  of  gastric 
juice,  49 
gastric,  dyspepsia  due   to  ab- 
normalities of,  30 

31 


Sinuses,  cerebral,  thrombosis  of, 

in  infantile  atrophy, 3 19,  330 
Skin,  diseases  of,  in  myasthenia 
gastrica,  127 
in  chronic  gastritis,  184 

gastroenteritis    of     infancy, 

325 
Slugs  in  stomach,  dyspepsia  due 

to,  298 
Smoking  as  cause  of  myasthenia 

gastrica,  11 1 
Snakes  in  stomach,  302 
Sounds,  splashing,  in  myasthenia 

gastrica,  120 
Spasm,   tonic,    of  extremities,  in 

chronic  hypersecretion,  83 
Specific  fevers,  dyspepsia  depend- 
ing upon,  387 
Spinal  cord,   diseases  of,   hyper- 
acidity associated  with,  33 
Splashing  sounds  in  myasthenia 

gastrica,  120 
Spots,    tender,    on   abdomen,    in 

gastric  neurasthenia,   224 
Stagnation  of  gastric  contents  in 

myasthenia  gastrica,   122 
Stenosis,  pyloric,  and  myasthenia 

gastrica,  differentiation,   132 
Stomach,  amphibia  in,  dyspepsia 
due  to,  300 

anadeny  of,  199 

anatomy  of,  242 

artificial  inflation,  in  gastrop- 
tosis,  264 

atony  of,  106 

beetles   in,   dyspepsia   due  to, 
290 

bezoars  in,  dyspepsia   due  to, 

275 
bile  in,  in  chronic  hypersecre- 
tion, 77 
carcinoma    of,     and    atrophic 
gastritis,      differentiation, 
208 
and    chronic    gastritis,    dif- 
ferentiation, 189 


482 


INDEX. 


Stomach,      carcinoma      of,    and 
chronic    hypersecretion, 
differentiation,  90 
and    neurasthenia    gastrica, 

differentiation,  230 
atrophic  gastritis  in,  201 
in  chronic  hypersecretion,  86 
in  hypersecretion,  59,  60 
catarrh  of,  172 
chill  of,  172 
coleoptera  in,  290 
concretions  in,   dyspepsia   due 

to,  277,  284 

contents,     chemical     analysis, 

in  myasthenia  gastrica,  129 

stagnation  of,  in  myasthenia 

gastrica,  122 

cough  in   initial   dyspepsia  of 

phthisis,  372 
dilatation     of,     and     gastrop- 
tosis,    differentiation,    268 
in      neurasthenia      gastrica, 

228 
in    pulmonary    tuberculosis, 
360 
diptera  in,  288 
diseases  of,    atrophic   gastritis 

in,  201 
displacements     of,     dyspepsia 
due  to,  242 
total,    255.     See    also    G as- 
tro ptosis. 
upward,    dyspepsia    due  to, 

243 
vertical,  angular  form,  246 
dyspepsia  due  to,  246 
fish-hook  variety,  247 
straight  variety,  247 
distention      of,       in      chronic 

hypersecretion,  65 
endarteritis  of,   from  syphilis, 

390 
eructation    of   gas    from,    236. 

See  also  Nervous  eructation. 
examination     of,     in     chronic 

hypersecretion,  74 


Stomach,    exploration    of,     with 
tube,  in  chronic  hypersecre- 
tion,  76 
fish-hook,  247 

foreign    bodies    in,    dyspepsia 
due  to,  275 
symptoms,  278 
treatment,  287 
galvanisation    of,     for    hyper- 
acidity, 49 
gumma  of,  389 
hemorrhagic     erosion     of,     in 

phthisis,  361 
hair-balls    in,     dyspepsia    due 
to,  276,  278 
duration     and     compli- 
cations, 281 
physical  signs,  280 
histological     appearances,      in 

infantile  atrophy,  311 
hour-glass,    in  chronic   hyper- 
secretion, 62 
hyperaesthesia    of,     211.       See 
also         Hypercesthesia         of 
stomach. 
inflammation      of,      dyspepsia 

due  to,  145 
insects   in,    dyspepsia  due   to, 
288 
symptoms,  294 
treatment,  298 
larva    in,    dyspepsia    due    to, 
288 
symptoms,  294 
treatment,  298 
lavage     of,     in     chronic     gas- 
tritis, 191 
hypersecretion,  75 
in  myasthenia  gastrica,  136 
leeches  in,   dyspepsia   due  to, 

300 
lepidoptera  in,  291 
living  creatures  in,    dyspepsia 

due  to,  287 
lizards    in,   dyspepsia    due    to 
299 


INDEX. 


483 


Stomach,     mamillation      of,      in 
phthisis,  361 
morbid  state  of,  in  phthisis,  360 
motor  insufficiency  of,  106 
in  chronic  gastritis,  187 
influence  of,  on  causation 
of    chronic    hypersecre- 
tion, 58 
iodipin  in  testing,   123 
Leube's  test  meal  for,  122 
salol  in  testing,  122,  123 
power  of,  in  chronic  hyper- 
secretion, 75 
mucous    membrane    of,    amy- 
loid   degeneration,    and 
atrophic  gastritis,  differ- 
entiation, 209 
atrophy  of,  199.     See  also 
Atrophic  gastritis. 
muscular  power  of,  dyspepsia 

due  to  failure  of,  106 
nervous    mechanism    of,    dys- 
pepsia   due    to    disturbance 
of,  211 
neurasthenia  of,  220.      See  also 

Neurasthenia  gastrica. 
slugs  in,  dyspepsia  due  to,  298 
snakes  in,  302 
stones    in,   dyspepsia    due    to, 

277,  284 
ulcer    of,    and    gastric    hyper- 
assthesia,      differentiation, 
216 
and    hyperacidity,    differen- 
tiation, 43 
and    neurasthenia    gastrica, 

differentiation,  231 
in  chronic  hypersecretion,  80 
in  hypersecretion,  59,  60,  61 
ulceration  of,  in  phthisis,  361 
vegetable  tumours  in,  dyspep- 
sia due  to,  283 
walls  of,  undue  distensibility, 
in  myasthenia  gastrica,  123 
worms   in,  dyspepsia    due    to, 
300  ' 


Stones    in    stomach,     dyspepsia 

due  to,  277,  284 
Subacidity,    20,     10 1.     See    also 

Achylia  gastrica. 
Superacidity,  30 
Sweat,    decrease    of,    in    chronic 

hypersecretion,  73 
Syphilis,   chronic  gastritis  from, 

391 
dyspepsia  depending  upon,  389. 

See  also  Dyspepsia. 
endarteritis  of  stomach  from, 

390 
gastritis  due  to,  395 


Taste,  perversions  of,  in  chronic 

hypersecretion,  71 
Tea,    strong,   as  cause  of  myas- 
thenia gastrica,  109 
Tender    spots    on    abdomen    in 

gastric  neurasthenia,  224 
Test,     iodipin,     for     motor     in- 
sufficiency of  stomach,    123 
meal,    Leube's,    for    motor  in- 
sufficiency of  stomach,  122 
salol,  for  motor  insufficiency  of 

stomach,  122,  123 
water-,    for    myasthenia    gas- 
trica, 129 
Tetany,  gastric,  in  chronic  hyper- 
secretion, 81 
in    chronic    hypersecretion, 
treatment,  99 
Thirst  in  chronic  gastritis,  182 
gastroenteritis     of     infancy, 

327 
hypersecretion,  71 
in  myasthenia  gastrica,  118 
in     terminal     dyspepsia    of 
phthisis,  376 
Thrombosis    of    cerebral    sinuses 
in  infantile  atrophy,  319,  330 
of    renal  veins    in    infantile 
atrophy,  317 
Tobacco  dyspepsia,  112 


484 


INDEX. 


Tongue  in  acute  hypersecretion, 

52 
in  chronic  gastritis,  1 83 

gastroenteritis    of     infancy, 

327 
hypersecretion,  71 
in  hyperacidity,  39 
in  initial  dyspepsia  of  phthisis, 

373 
in  myasthenia  gastrica,  119 
in       terminal      dyspepsia      of 
phthisis,  377 
Tonic   spasm   of   extremities    in 

chronic  hypersecretion,  83 
Toux  gastrique,  372 
Toxic  gastritis,  acute,   167.      See 

also    Gastritis,    acute    toxic. 
Tuberculosis,  miliary,  in  infantile 
atrophy,  331 
pulmonary.     See  Phthisis. 
Tumours,  vegetable,  in  stomach, 

dyspepsia  due  to,  283 
Turck's     internal      masseur     in 
myasthenia  gastrica,  137 
needle-douche    in    myasthenia 
gastrica,  137 


Ulcer,     duodenal,     in     chronic 
hypersecretion,  60,  61 
of  stomach  and  gastric  hyper- 
aesthesia,      differentiation, 
216 
and    hyperacidity,    differen- 
tiation, 43 
and     neurasthenia    gastrica, 

differentiation,  231 
in     chronic    hypersecretion, 

80 
in  hypersecretion,  59,  60,  61 
Ulceration  of'stomach  in  phthisis, 

361 
Uratic    concretions    in    infantile 

atrophy,  318 
Urea  in  chronic  hypersecretion, 
72 


Urinary  organs,  diseases  of,  dys- 
pepsia    depending    upon, 

383 
dyspepsia   depending   upon, 
symptoms,  385 
treatment,  386 
Urine,  chlorides  in,  decrease  in, 
in     chronic     hypersecretion, 

73 
in  acute  hypersecretion,  52 
in  chronic  gastritis,  183 

gastroenteritis    of     infancy, 

327 

hypersecretion,  72 
in    myasthenia   gastrica,    120, 

127 
phosphates      in,      in      chronic 

hypersecretion,  72 


Varieties  of  dyspepsia,  17,  20 
Vegetable  tumours  in  stomach, 

dyspepsia  due  to,  283 
Veins,    renal,    thrombosis   of,    in 

infantile  atrophy,  317 
Vermiform  appendix,  diseases  of, 
in    chronic  hypersecretion,  60, 
61 
Vomit,   character  of,   in  chronic 

hypersecretion,  68 
Vomiting    in    acute    hypersecre- 
tion, 51 
in  chronic  gastritis,  180 

gastroenteritis    of     infancy, 

322 
hypersecretion,  66 
in  dyspepsia  due  to  pregnancy, 

403 

from  syphilis,  393 
in   hyperaesthesia  of    stomach, 

214 
in  hyperacidity,  39 
in  initial  dyspepsia  of  phthisis, 

370 
in    myasthenia   gastrica,    118, 
.  126 


INDEX. 


485 


Vomiting  in  terminal  dyspepsia 
of  phthisis,  376 
nocturnal,    in    chronic    hyper- 
secretion, 67 
periodic,     in     chronic     hyper- 
secretion, 66 
Vomitus    matutinus    in    chronic 
gastritis,  181 


Waterbrash  in  chronic  gastritis, 

182 
Waters,  mineral,  in  chronic  gas- 
tritis, 195 
in  myasthenia  gastrica,  138 
Water-test  for  myasthenia   gas- 
trica, 129 
Worms    in    stomach,    dyspepsia 
due  to,  300 


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uterine  fibroids  is  discussed.  It  is  a  splendid  example  of  the  rapid  progress  of  American  pro- 
fessional thought." 

Bulletin  Medical  and  Chirurgical  Faculty  of  Maryland 

"  Few  medical  works  in  recent  years  have  come  to  our  notice  so  complete  in  detail,  so 
well  illustrated,  so  practical,  and  so  far  reaching  in  their  teaching  to  general  practitioner, 
specialist,  and  student  alike." 


GYNECOLOGY  AND    OBSTETRICS 


Cullen*s 
Adenomyoma  qf  the  Uterus 


Adenomyoma  of  the  Uterus.  By  Thomas  S.  Cullen,  M.  D., 
Associate  Professor  of  Gynecology,  Johns  Hopkins  University.  Octavo 
of  275  pages,  with  original  illustrations  by  Hermann  Becker  and 
August  Horn.     Cloth,  ^5.00  net;    Half  Morocco,  ^6.50  net. 

SUPERB  ILLUSTRATIONS 

Dr.  Cullen' s  large  clinical  experience  and  his  extensive  original  work  along 
the  lines  of  gynecologic  pathology  have  enabled  him  to  present  his  subject  with 
originality  and  precision.  The  work  gives  the  early  literature  on  adenomyoma, 
traces  the  disease  through  its  various  stages,  and  then  gives  the  detailed  findings 
in  a  large  number  of  cases  personally  examined  by  the  author.  Formerly  the 
physician  and  surgeon  were  unable  to  determine  the  cause  of  uterine  bleeding,  but 
after  following  closely  the  clinical  course  of  the  disease,  Dr.  Cullen  has  found  that 
the  majority  of  these  cases  can  be  diagnosed  clinically.  The  results  of  these 
observations  he  presents  in  this  work.  The  superb  illustrations  are  the  work  of 
Mr.  Hermann  Becker  and  Mr.  August  Horn,  of  the  Johns  Hopkins  Hospital. 

The  Lancet,  London 

"  A  good  example  of  how  such  a  monograph  should  be  written.  It  is  an  excellent  work, 
worthy  of  the  high  reputation  of  the  author  and  of  the  school  from  which  it  emanates." 


Cullen*s  Cancer  of  the  Uterus 

Cancer  of  the  Uterus.  By  Thomas  S.  Cullen,  M.  B.,  Associate 
Professor  of  Gynecology,  Johns  Hopkins  University.  Large  octavo  of 
693  pages,  with  over  300  colored  and  half-tone  text-cuts  and  eleven 
lithographs.     Cloth,  $7.50  net ;  Half  Morocco,  ^8.50  net. 

THE  RECOGNIZED  AUTHORITY 

Realizing  that  it  is  most  frequently  the  general  practitioner  upon  whom  rests 
the  responsibility  of  first  diagnosing  cancer  of  the  uterus,  and  that  the  prognosis 
depends  very  largely  upon  an  early  diagnosis,  Dr.  Cullen  has  taken  special  pains 
to  make  clear  the  first  signs.  Treatment  he  has  detailed  with  that  care  and  pre- 
ciseness  so  characteristic  of  all  his  work. 

Howard  A.  Kelly,  M.  D.,  Johns  Hopkins  University. 

"Dr.  Cullen's  book  is  the  standard  work  on  the  greatest  problem  which  faces  the  sur- 
gical world  to-day.    Any  one  who  desires  to  attack  this  great  problem  must  have  this  book." 


SAUNDERS'   BOOKS   ON 


Ashton*s 
Practice  of  Gynecology 


The  Practice  of  Gynecology.  By  W.  Easterly  Ashton,  M.  D., 
LL.D.,  Professor  of  Gynecology  in  the  Medico-Chirurgical  College, 
Philadelphia.  Handsome  octavo  volume  of  1099  pages,  containing  1058 
original  line  drawings.     Cloth,  $6.50  net;  Half  Morocco,  ^8.00  net. 

JUST  READY- THE   NEW    (4th)    EDITION 
FOUR   EDITIONS   IN   FOUR  YEARS 

Four  large  editions  of  Dr.  Ashton' s  work  have  been  required  in  as 
many  years.  The  author  takes  up  each  procedure  necessary  to  gynecologic 
step  by  step,  the  student  being  led  from  one  step  to  another,  just  as  in  studying 
any  non-medical  subject,  the  minutest  detail  being  explained  in  language  that 
cannot  fail  to  be  understood  even  at  first  reading.  Nothing  is  left  to  be  taken  for 
granted,  the  author  not  only  telling  his  readers  in  every  instance  what  should  be 
done,  but  also  precisely  how  to  do  it.  A  distinctly  original  feature  of  the  book  is 
the  illustrations,  numbering  1058  line  drawings  made  especially  under  the  author's 
personal  supervision  from  actual  apparatus,  living  models,  and  dissections  on  the 
cadaver. 

From  its  first  appearance  Dr.  Ashton' s  book  set  a  standard  in  practical 
medical  books  ;  that  he  has  produced  a  work  of  unusual  value  to  the  medical 
practitioner  is  shown  by  the  demand  for  new  editions.  Indeed,  the  book  is  a 
rich  store-house  of  practical  information,  presented  in  such  a  way  that  the  work 
cannot  fail  to  be  of  daily  service  to  the  practitioner. 

Howard  A.  Kelly.  M.  D. 

Professor  of  Gynecologic  Surgery,  Johns  Hopkins  University. 

"  It  is  different  from  anything  that  has  as  yet  appeared.  The  illustrations  are  particularly 
clear  and  satisfactory.  One  specially  good  feature  is  the  pains  with  which  you  describe  so 
many  details  so  often  left  to  the  imagination." 

Cheirles  B.  Penrose,  M.  D. 

Formerly  Professor  of  Gynecology  in  the  University  of  Pe7insylvania 

"  I  know  of  no  book  that  goes  so  thoroughly  and  satisfactorily  into  all  the  details  of  every- 
thing connected  with  the  subject.     In  this  respect  your  book  differs  from  the  others." 

George  M.  Edebohls,  M.  D. 

Professor  of  Diseases  of  Women,  New  York  Post-Graduate  Medical  School 
"A  text-book  most  admirably  adapted  to  teach  gynecology  to  those  who  must  get  theh 
Vnowledge,  even  to  the  minutest  and  most  elementary  details,  from  books." 


GYNECOLOGY  AND    OBSTETRICS 


Bandler*s 
Medical    Gynecology 


Medical  Gynecology.  By  S.  Wyllis  Bandler,  M.  D.,  Adjunct 
Professor  of  Diseases  of  Women,  New  York  Post-Graduate  Medical 
School  and  Hospital.  Octavo  of  702  pages,  with  150  original  illus- 
trations.    Cloth,  $5.00  net;  Half  Morocco,  ^6.50  net. 

RECENTLY   ISSUED— THE  NEW    (2d)    EDITION 
EXCLUSIVELY    MEDICAL    GYNECOLOGY 

This  new  work  by  Dr.  Bandler  is  just  the  book  that  the  physician  engaged  in 
general  practice  has  long  needed.  It  is  truly  the  pr'actitioner  s  gynecology — planned 
for  him,  written  for  him,  and  illustrated  for  him.  There  are  many  gynecologic 
conditions  that  do  not  call  for  operative  treatment ;  yet,  because  of  lack  of  that 
special  knowledge  required  for  their  diagnosis  and  treatment,  the  general  practi- 
tioner has  been  unable  to  treat  them  intelligently.  This  work  gives  just  the  in- 
formation the  practitioner  needs.  It  not  only  deals  with  those  conditions  amen- 
able to  non-operative  treatment,  but  it  also  tells  how  to  recognize  those  diseases 
demanding  operative  treatment,  so  that  the  practitioner  will  be  enabled  to  advise 
his  patient  at  a  time  when  operation  will  be  attended  with  the  most  favorable 
results.  The  chapter  on  Pessaries  is  especially  full  and  excellent,  the  proper 
manner  of  introducing  the  pessary  being  clearly  described  and  illustrated  with 
original  pictures  that  show  plainly  the  correct  technic  of  this  procedure.  The 
chapters  on  Vaginal  and  Abdominal  Massage,  and  particularly  that  on  Artificial 
Hyperemia  and  Anemia,  are  extremely  valuable  to  the  practitioner.  They  express 
the  very  latest  advances  in  these  methods  of  treatment.  Hydrotherapy,  especially 
the  Ferguson  and  Nauheim  Baths,  are  treated  in  extenso,  and  Electrotherapy 
receives  the  full  consideration  its  importance  merits. 

American  Journal  of  Obstetrics 

"  He  has  shown  good  judgment  in  the  selection  of  his  data.  He  has  placed  most  emphasis 
on  diagnostic  and  therapeutic  aspects.  He  has  presented  his  facts  in  a  manner  to  be  readily 
grasped  by  the  general  practitioner." 

Surgery,  Gynecology,  and  Obstetrics 

"  The  volume  has  been  prepared  especially  for  the  general  practitioner.  .  .  .  The 
chapter  on  Gonorrhea  is  one  deserving  of  special  mention,  having  never  been  so  well  presented 
aside  from  elaborate  monograph  presentation." 


SAUNDERS'    BOOKS    ON 


Kelly  and   Noble's 

Gynecology 

and  Abdominal  Surgery 


Gynecology  and  Abdominal  Surgery.  Edited  by  Howard  A. 
Kelly,  M.  D.,  Professor  of  Gynecology  in  Johns  Hopkins  University ; 
and  Charles  P.  Noble,  M.  D.,  Clinical  Professor  of  Gynecology  in  the 
Woman's  Medical  College,  Philadelphia.  Two  imperial  octavo  volumes 
of  950  pages  each,  containing  880  illustrations,  some  in  colors.  Per 
volume :  Cloth,  ;$8.oo  net ;  Half  Morocco,  $g.<,o  net. 

BOTH     VOLUMES     NOW     READY 
WITH  880  ILLUSTRATIONS   BY  HERMANN  BECKER  AND   MAX  BRODEL 

In  view  of  the  intimate  association  of  gynecology  with  abdominal  surgery  the 
editors  have  combined  these  two  important  subjects  in  one  work.  For  this  reason 
the  work  will  be  doubly  valuable,  for  not  only  the  gynecologist  and  general  prac- 
titioner will  find  it  an  exhaustive  treatise,  but  the  surgeon  also  will  find  here  the 
latest  technic  of  the  various  abdominal  operations.  It  possesses  a  number  of 
valuable  features  not  to  be  found  in  any  other  publication  covering  the  same  fields. 
It  contains  a  chapter  upon  the  bacteriology  and  one  upon  the  pathology  of  gyne- 
cology, dealing  fully  with  the  scientific  basis  of  gynecology.  In  no  other  work 
can  this  information,  prepared  by  specialists,  be  found  as  separate  chapters. 
There  is  a  large  chapter  devoted  entirely  to  7}iedical  gynecology  written  especially 
for  the  physician  engaged  in  general  practice.  Heretofore  the  general  practitioner 
was  compelled  to  search  through  an  entire  work  in  order  to  obtain  the  information 
desired.  Abdominal  surgery  proper,  as  distinct  from  gynecology,  is  fully  treated, 
embracing  operations  upon  the  stomach,  upon  the  intestines,  upon  the  liver  and 
bile-ducts,  upon  the  pancreas  and  spleen,  upon  the  kidneys,  ureter,  bladder,  and 
the  peritoneum.  The  illustrations  are  truly  magnificent,  being  the  work  of  Mr, 
Hermann  Becker  and  Mr.  Max  Brodel. 

American  Journal  of  the  Medical  Sciences 

"It  is  needless  to  say  that  the  work  has  been  thoroughly  done :  the  names  of  the  authors 
and  editors  would  guarantee  this ;  but  much  may  be  said  in  praise  of  the  method  of  presen- 
tation, and  attention  may  be  called  to  the  inclusion  of  matter  not  to  be  found  elsewhere." 


G  YNECOL OGY  AND  OBS TE TRIGS 


Webster's 
Text-Book  qf  Obstetrics 

A  Text-Book  of  Obstetrics.  By  J.  Clarence  Webster,"  M.  D. 
(Edin.),  F.  R.  C.  p.  E.,  Professor  of  Obstetrics  and  Gynecology  in  Rush 
Medical  College,  in  affiliation  with  the  University  of  Chicago.  Octavo 
volume  of  767  pages,  illustrated.  Cloth,  ^5.00  net;  Half  Morocco, 
$6.^0  net. 

BEAUTIFULLY     ILLUSTRATED 

In  this  work  the  anatomic  changes  accompanying  pregnancy,  labor,  and  the 
puerperium  are  described  more  fully  and  lucidly  than  in  any  other  text-book  on 
the  subject.  The  exposition  of  these  sections  is  based  mainly  upon  studies  of 
frozen  specimens.  Unusual  consideration  is  given  to  embryologic  and  physiologic 
data  of  importance  in  their  relation  to  obstetrics. 

Buffalo  Medical  Journal 

"  As  a  practical  text-book  on  obstetrics  for  both  student  and  practitioner,  there  is  left  very 
little  to  be  desired,  it  being  as  near  perfection  as  any  compact  work  that  has  been  published." 


Webster's 
Diseases  of  Women 

A  Text-=Book  of  Diseases  of  Women.  By  J.  Clarence  Webster, 
M.  D.  (Edin.),  F.  R.  C.  P.  E.,  Professor  of  Gynecology  and  Obstetrics 
in  Rush  Medical  College.  Octavo  of  712  pages,  with  372  text-illustra- 
tions and  10  colored  plates.     Cloth,  ;^7.00  net;  Half  Morocco,  $Z.^O  net. 

Dr.  Webster  has  written  this  work  especially  for  the  general  practitioner,  dis- 
cussing the  clinical  features  of  the  subject  in  their  widest  relations  to  general 
practice  rather  than  from  the  standpoint  of  specialism.  The  magnificent  illus- 
trations, three  hundred  and  seventy-two  in  number,  are  nearly  all  original. 

Howard  A.  Kelly.  M,  D. 

Professor  of  Gynecologic  Surgery,  Johns  Hopkins  University. 

"It  is  undoubtedly  one  of  the  best  works  which  has  been  put  on  the  market  within  recent 
years,  showing  from  start  to  finish  Dr.  Webster's  well-known  thoroughness.  The  illustrations 
are  also  of  the  highest  order." 


SAUNDERS'   BOOKS   ON 


Hirst's 
Text-Book  of  Obstetrics 

Just  Ready — The  New  (6th)  Edition 


A  Text=Book  of  Obstetrics.  By  Barton  Cooke  Hirst,  M.  D., 
Professor  of  Obstetrics  in  the  University  of  Pennsylvania.  Handsome 
octavo,  992  pages,  with  847  illustrations,  43  of  them  in  colors.  Cloth, 
^5.00  net;  Half  Morocco,  ^6.50  net. 

INCLUDING  RELATED  GYNECOLOGIC  OPERATIONS 

Immediately  on  its  publication  this  work  took  its  place  as  the  leading  text-book 
on  the  subject.  Both  in  this  country  and  in  England  it  is  recognized  as  the  most 
satisfactorily  written  and  clearly  illustrated  work  on  obstetrics  in  the  language. 
The  illustrations  form  one  of  the  features  of  the  book.  They  are  numerous  and 
the  most  of  them  are  original.  In  this  edition  the  book  has  been  thoroughly  revised. 
Recognizing  the  inseparable  relation  between  obstetrics  and  certain  gynecologic 
conditions,  the  author  has  included  all  the  gynecologic  operations  for  complica- 
tions and  consequences  of  childbirth,  together  with  a  brief  account  of  the  diagnosis 
and  treatment  of  all  the  pathologic  phenomena  peculiar  to  women. 


OPINIONS  OF  THE  MEDICAL  PRESS 


British  Medical  Journal 

"  The  popularity  of  American  text-books  in  this  country  is  one  of  the  features  of  recent 
years.  The  popularity  is  probably  chiefly  due  to  the  great  superiority  of  their  illustrations 
over  those  of  the  English  text-boolis.  The  illustrations  in  Dr.  Hirst's  volume  are  far  more 
numerous  and  far  better  executed,  and  therefore  more  instructive,  than  those  commonly 
found  in  the  works  of  writers  on  obstetrics  in  our  own  country." 

Bulletin  of  Johns  Hopkins  Hospital 

"The  work  is  an  admirable  one  in  every  sense  of  the  word,  concisely  but  comprehensively 
written." 

The  Medical  Record,  New  York 

"The  illustrations  are  numerous  and  are  works  of  art,  many  of  them  appearing  for  the  first 
time.  The  author's  style,  though  condensed,  is  singularly  clear,  so  that  it  is  never  necessary 
to  re-read  a  sentence  in  order  to  grasp  the  meaning.  As  a  true  model  of  what  a  modern  text- 
book on  obstetrics  should  be,  we  feel  justified  in  affirming  that  Dr.  Hirst's  book  is  without  a 
rival." 


DISEASES   OF    WOMEN. 


HirstV 
Diseases  of  Women 


A  Text=Book  of  Diseases  of  Women.  By  Barton  Cooke  Hirst, 
M.  D.,  Professor  of  Obstetrics,  University  of  Pennsylvania ;  Gynecolo- 
gist to  the  Howard,  the  Orthopedic,  and  the  Philadelphia  Hospitals. 
Octavo  of  745  pages,  with  701  original  illustrations,  many  in  colors. 
Cloth,  ^5.00  net;  Half  Morocco,  $6.50  net. 

THE    NEW   (2d)    EDITION 
WITH    701    ORIGINAL    ILLUSTRATIONS 

The  new  edition  of  this  work  has  just  been  issued  after  a  careful  revision. 
As  diagnosis  and  treatment  are  of  the  greatest  importance  in  considering  diseases 
of  women,  particular  attention  has  been  devoted  to  these  divisions.  To  this  end, 
also,  the  work  has  been  magnificently  illuminated  with  701  illustrations,  for  the 
most  part  original  photographs  and  water-colors  of  actual  clinical  cases  accumu- 
lated during  the  past  fifteen  years.  The  palliative  treatment,  as  well  as  the 
radical  operative,  is  fully  described,  enabling  the  general  practitioner  to  treat 
many  of  his  own  patients  v.  ithout  referring  them  to  a  specialist.  An  entire  sec- 
tion is  devoted  to  ?_  full  description  of  all  modern  gynecologic  operations,  illumi- 
nated and  elucidalied  by  numerous  photographs.  The  author's  extensive  ex- 
perience renders  this  work  of  unusual  value. 


OPINIONS  OF  THE  MEDICAL  PRESS 


Medical  Record,  New  York 

"  Its  merits  can  be  appreciated  only  by  a  careful  perusal.  .  .  .  Nearly  one  hundred  pages 
are  devoted  to  technic,  this  chapter  being  in  some  respects  superior  to  the  descriptions  in 
many  other  text-  boles." 

Boston  Medical  and  Surgical  Journal 

"The  author  has  given  special  attention  to  diagnosis  and  treatment  throughout  the  book, 
and  has  produced  a  practical  treatise  which  should  be  of  the  greatest  value  to  the  student,  the 
general  practitioner,  and  the  specialist." 

Medical  News,  New  York 

"Office  treatment  is  given  a  due  amount  of  consideration,  so  that  the  work  will  be  as 
useful  to  the  non-operator  as  to  the  specialist." 


SAUNDERS'    BOOKS   ON 


GET  ^  •  THE  NEW 

THE  BEST  /\  m  6  r  1  C  Si  n  standard 

Illustrated   Dictionary 

Recently  Issued — The  New  (5th)  Edition 


The  American  Illustrated  Medical  Dictionary.  A  new  and  com- 
plete dictionary  of  the  terms  used  in  Medicine,  Surgery,  Dentistry, 
Pharmacy,  Chemistry,  and  kindred  branches ;  with  over  lOO  new  and 
elaborate  tables  and  many  handsome  illustrations.  By  W.  A.  Newman 
Borland,  M.  D.,  Editor  of  "  The  American  Pocket  Medical  Dicdon- 
ary."  Large  octavo,  nearly  8/6  pages,  bound  in  full  flexible  leather. 
Price,  $\.^o  net;  with  thumb  index,  ^5.00  net. 

A  KEY  TO  MEDICAL  LITERATURE 

Gives  a  Maximum  Amount  of  Matter  in  a  Minimum  Space 

WITH   2000   NEW  TERMS 

We  really  believe  that  Dorland's  Dictionary  is  the  most  useful  single  book  that 
the  medical  practitioner  can  own.  We  are  confident  you  will  get  more  real  use 
out  of  it  than  out  of  any  one  book  you  ever  bought. 

Nearly  every-  medical  paper  to-day  contains  special  words  which  are  new  to  most 
readers.  \i you  want  to  get  the  best  out  of  your  journals  and  text-books,  Dorland's 
Dictionary  should  be  on  your  desk  for  ready  reference. 

This  new  edition  contains  2000  new  words.  Hundreds  of  these  cannot  be  found 
in  any  other  dictionary.     Of  this  edition  5000  have  been  sold  in  two  months. 


PERSONAL   OPINIONS 


Howard  A.  Kelly,  M.  D., 

Professor  of  Gynecologic  Surgery,  Johns  Hopkins  University ,  Baltimore 
"  Dr.  Dorland's  dictionary  is  admirable.     It  is  so  well  gotten  up  and  of  such  convenient 
size.     No  errors  have  been  found  in  my  use  of  it." 

J.  Collins  Warren,  M.D..  LL.D.,  F.R.C.S.  (Hon.) 

Professor  of  Surgery^  Harvard  Medical  School. 

"  I  regard  it  as  a  valuable  aid  to  my  medical  literary  work.     It  is  very  complete  and  of 
convenient  size  to  handle  comfortably.     I  use  it  in  preference  to  any  other." 


GYNECOLOGY  AND    OBSTETRICS 


Penrose's 
Diseases  of  Women 

Sixth    Revised    Edition 


A  Text-Book  of  Diseases  of  Women.  By  Charles  B.  Penrose, 
M.  D.,  Ph.  D.,  formerly  Professor  of  Gynecology  in  the  University  of 
Pennsylvania ;  Surgeon  to  the  Gynecean  Hospital,  Philadelphia.  Oc- 
tavo volume  of  550  pages,  with  225  fine  original  illustrations.     Cloth, 

.^3-75  net. 

ILLUSTRATED 

Regularly  every  year  a  new  edition  of  this  excellent  text-book  is  called  for, 
and  it  appears  to  be  in  as  great  favor  with  physicians  as  with  students.  Indeed, 
this  book  has  taken  its  place  as  the  ideal  work  for  the  general  practitioner.  The 
author  presents  the  best  teaching  of  modern  gynecology,  untrammeled  by  anti- 
quated ideas  and  methods.  In  every  case  the  most  modern  and  progressive 
technique  is  adopted,  and  the  main  points  are  made  clear  by  excellent  illustra- 
tions. The  new  edition  has  been  carefully  revised,  much  new  matter  has  been 
added,  and  a  number  of  new  original  illustrations  have  been  introduced.  In  its 
revised  form  this  volume  continues  to  be  an  admirable  exposition  of  the  present 
status  of  gynecologic  practice. 


PERSONAL  AND  PRESS  OPINIONS 


Howard  A.  Kelly,  M.  D., 

Professor  of  Gynecologic  Surgery y  Johns  Hopkins  University ,  Baltimore. 
"  I  shall  value  very  highly  the  copy  of  Penrose's  '  Diseases  of  Women  '  received.     I  have 
already  recommended  it  to  my  class  as  THE  BEST  book." 

E.  E.  Montgomery,  M.  D., 

Professor  of  Gynecology,  Jefferson  Medical  College,  Philadelphia. 
"  The  copy  of '  A  Text-Book  of  Diseases  of  Women  '  by  Penrose,  received  to-day.     I  have 
looked  over  it  and  admire  it  very  much.     I  have  no  doubt  it  will  have  a  large  sale,  as  it  justly 
merits." 

Bristol  Medico-Chimrgical  Journal 

"  This  is  an  excellent  work  which  goes  straight  to  the  mark.  .  .  .  The  book  may  be  taken 
as  a  trustworthy  exposition  of  modern  gynecology." 


I*  SAUNDERS'    BOOKS   ON 

Dorland's 
Modern   Obstetrics 


Modern  Obstetrics:  General  and  Operative.     By  W.  A.  Newman 

Borland,  A.  M.,  M.  D.,  Assistant  Instructor  in  Obstetrics,  Univer- 
sity of  Pennsylvania ;  Associate  in  Gynecology  in  the  Philadelphia 
Polyclinic.  Handsome  octavo  volume  of  797  pages,  with  201  illustra- 
tions.    Cloth,  ;^4.oo  net. 

Second  Edition,  Revised  and  Greatly  Enlarged 

In  this  edition  the  book  has  been  entirely  rewritten  and  very  greatly  enlarged. 
Among  the  new  subjects  introduced  are  the  surgical  treatment  of  puerperal  sepsis, 
infant  mortality,  placental  transmission  of  diseases,  serum-therapy  of  puerperal 
sepsis,  etc.  By  new  illustrations  the  text  has  been  elucidated,  and  the  subject  pre- 
sented in  a  most  instructive  and  acceptable  form. 

Journal  of  the  American  Medical  Association 

"  This  work  deserves  commendation,  and  that  it  has  received  what  it  deserves  at  the  hands 
of  the  profession  is  attested  by  the  fact  that  a  second  edition  is  called  for  within  such  a  short 
time.     Especially  deserving  of  praise  is  the  chapter  on  puerperal  sepsis." 

Davis*  Obstetric  and 
Gynecologic  Nursing 

Obstetric  and  Gynecologic  Nursing.    By  Edward  P.  Davis,  A.  M., 
M.  D.,   Professor   of  Obstetrics    in   the  Jefferson  Medical   College  and 
Philadelphia   PolycHnic ;    Obstetrician    and    Gynecologist,   Philadelphia 
Hospital.      i2mo  of  436  pages,  illustrated.     Buckram,  $1.7$  net. 
THE     NEW    (3d)    EDITION 

Obstetric  nursing  demands  some  knowledge  of  natural  pregnancy,  and  gyne- 
cologic nursing,  really  a  branch  of  surgical  nursing,  requires  special  instruction 
and  training.  This  volume  presents  this  information  in  the  most  convenient 
form.  This  third  edition  has  been  very  carefully  revised  throughout,  bringing  the 
subject  down  to  date. 

The  Lancet,  London 

"  Not  only  nurses,  but  even  newly  qualified  medical  men,  would  learn  a  great  deal  by  a 
perusal  of  this  book.  It  is  written  in  a  clear  and  pleasant  style,  and  is  a  work  we  can  recom- 
mend." 


GYNECOLOGY  AND    OBSTETRICS.  13 

Garrigues* 
Diseases  of  Women 

Third  Edition,  Thoroughly  Revised 


A  Text-Book  of  Diseases  of  Women.  By  Henry  J.  Garrigues, 
A.  M.,  M.  D.,  Gynecologist  to  St.  Mark's  Hospital  and  to  the  German 
Dispensary,  New  York  City.  Handsome  octavo,  756  pages,  with  367 
engravings  and  colored  plates.  Cloth,  ^4.50  net;  Sheep  or  Half 
Morocco,  ;^6.oo  net. 

The  first  two  editions  of  this  work  met  with  a  most  appreciative  reception  by 
the  medical  profession  both  in  this  country  and  abroad.  In  this  edition  the  entire 
work  has  been  carefully  and  thoroughly  revised,  and  considerable  new  matter 
added,  bringing  the  work  precisely  down  to  date.  Many  new  illustrations  have  been 
introduced,  thus  greatly  increasing  the  value  of  the  book  both  as  a  text-book  and 
book  of  reference. 

Thad.  A.  Reamy,  M.  D.,   Professor  of  Clinical  Gytiecology,  Medical  College  of  Ohio. 

"One  of  the  best  text-books  for  students  and  practitioners  which  has  been  published  in  the 
English  language  ;  it  is  condensed,  clear,  and  comprehensive.  The  profound  learning  and 
great  clinical  experience  of  the  distinguished  author  find  expression  in  this  book." 


American  Text-Book  qf  Gynecology 

Second    Revised    Edition 
American   Text=Book  of   Gynecology.     Edited   by  J.    M.    Baldy, 
M.  D.     Imperial  octavo  of  718  pages,  with  341   text-illustrations  and 
38  plates.     Cloth,  ^6.00  net, 

American  Text-Book  qf  Obstetrics 

Second    Revised    Edition 
The  American  Text=Book  of  Obstetrics.     In  two  volumes.    Edited 
by  Richard  C.  Norris,  M.  D.  ;  Art  Editor,  Robert  L.  Dickinson,  M.  D. 
Two  octavos  of  about  600  pages  each ;  nearly  900  illustrations,  includ- 
ing 49  colored  and  half-tone  plates.      Per  volume  :  Cloth,  ^3.50  net. 

"  As  an  authority,  as  a  book  of  reference,  as  a  '  working  book  '  for  the  student  or  practi- 
tioner, we  commend  it  because  we  believe  there  is  no  better." — American  Journal  of  the 
Medical  Sciences. 


14  SAUNDERS'    BOOKS   ON 

Schaffer  and  £dgar*s  Labor  and  Operative  Obstetrics 

Atlas  and   Epitome  of    Labor    and    Operative    Obstetrics.      By   Dr. 

O.  Schaffer,  of  Heidelberg.  Edited,  with  additions,  by  J.  Clifton  Edgar, 
M.  D.,  Professor  of  Obstetrics  and  Clinical  Midwifery,  Cornell  University 
Medical  School,  New  York.  With  14  lithographic  plates  in  colors,  139  text- 
cuts,  and  III  pages  of  text.      Cloth,  $2.00  net.     In  Saimders'  Hand-Atlases.- 

American  Medicine 

"  It  would  be  difficult  to  find  one  hundred  pages  in  better  form  or  containing  more 
practical  points  for  students  or  practitioners." 

Schaffer     and     Ed|(ar's     Obstetric     Diag'nosis     and 
Treatment 

Atlas  and  Epitome  of  Obstetric  Diagnosis  and   Treatment.    By  Dr. 

O.  Schaffer,  of  Heidelberg.  Edited,  with  additions,  by  J.  Clifton  Edgar, 
M.  D.,  Professor  of  Obstetrics  and  Clinical  Midwifery,  Cornell  University 
Medical  School,  New  York.  With  122  colored  figures  on  56  plates,  38  text- 
cuts,  and  315  pages  of  text.      Cloth,   ^3.00  net.      Saunders'  Hand-Atlases. 

New  York  Medical  Journal 

' '  The  illustrations  are  admirably  executed,  as  they  are  in  all  of  these  atlases,  and  the  text 
can  safely  be  commended." 

Schaffer  and  Norris*  Gynecology 

Atlas  and  Epitome  of  Gynecology.  By  Dr.  O.  Schaffer,  of  Heidel- 
berg. Edited,  with  additions,  by  Richard  C.  Norris,  A.  M.,  M.  D., 
Gynecologist  to  Methodist  Episcopal  and  Philadelphia  Hospitals.  With  207 
colored  figures  on  90  plates,  65  text-cuts,  and  308  pages  of  text.  Cloth, 
^3.50  net.      In  Saunders'  Hand-Atlas  Series. 

American  Journal  of  the  Medical  Sciences 

"  Of  the  illustrations  it  is  difficult  to  speak  in  too  high  terms  of  approval.  They  are  so 
clear  and  true  to  nature  that  the  accompanying  explanations  are  almost  superfluous." 

Galbraith*s  Four  Epochs  of  Woman's   Life 

New  (2d)  Edition 

The  Four  Epochs  of  Woman's  Life :  A  Study  in  Hygiene.  By  Anna 
M.  Galbraith,  M.  D.,  Fellow  of  the  New  York  Academy  of  Medicine,  etc. 
With  an  Introductory  Note  by  John  H.  Musser,  M.  D.,  University  of 
Pennsylvania.      i2mo  of  247  pages.      Cloth,  $1.50  net. 

Birmingham  Medical  Review,  England 

"  We  do  not,  as  a  rule,  care  for  medical  books  written  for  the  instruction  of  the  public. 
But  we  must  admit  that  the  advice  in  Dr.  Galbraith's  work  is,  in  the  main,  wise  and 
wholesome." 


GYNECOLOGY  AND    OBSTETRICS.  15 

Schaffer  and  Webster's 
Operative  Gynecology 


Atlas  and  Epitome  of  Operative  Gynecology.  By  Dr.  O.  Schaf- 
fer, of  Heidelberg-.  Edited,  with  additions,  by  J.  Clarence  Webster, 
M.D.  (Edin.),  F.R.C.P.E.,  Professor  of  Obstetrics  and  Gynecology  in 
Rush  Medical  College,  in  affiliation  with  the  University  of  Chicago. 
42  colored  lithographic  plates,  many  text-cuts,  a  number  in  colors,  and 
138  pages  of  text.     In  Saunders'  Hand- Atlas  Series.    Cloth,  ^3.00  net. 


Much  patient  endeavor  has  been  expended  by  the  author,  the  artist,  and  the 
lithographer  in  the  preparation  of  the  plates  of  this  atlas.  They  are  based  on 
hundreds  of  photographs  taken  from  nature,  and  illustrate  most  faithfully  the 
various  surgical  situations.  Dr.  Schaffer  has  made  a  specialty  of  demonstrating 
by  illustrations. 

Medical  Record,  New  York 

"  The  volume  should  prove  most  helpful  to  students  and  others  in  grasping  details  usually 
to  be  acquired  only  in  the  amphitheater  itself." 

De  Lee*s 
Obstetrics  for  Nurses 


Obstetrics  for  Nurses.  By  Joseph  B.  De  Lee,  M.D.,  Professor  of 
Obstetrics  in  the  Northwestern  University  Medical  School ;  Lecturer 
in  the  Nurses'  Training  Schools  of  Mercy,  Wesley,  Provident,  Cook 
County,  and  Chicago  Lying-in  Hospitals.  i2mo  volume  of  512  pages, 
fully  illustrated.  Cloth,  $2.50  net. 

THE     NEW    (3d)    EDITION 

While  Dr.  De  Lee  has  written  his  work  especially  for  nurses,  yet  the  prac- 
titioner will  find  it  useful  and  instructive,  since  the  duties  of  a  nurse  often  devolve 
upon  him  in  the  early  years  of  his  practice.  The  illustrations  are  nearly  all 
original,  and  represent  photographs  taken  from  actual  scenes.  The  text  is  the 
result  of  the  author's  many  years'  experience  in  lecturing  to  the  nurses  of  five 
different  training  schools. 

J.  Clifton  Edgar,  M.  D., 

Professor  of  Obstetrics  and  Clinical  Midwifery,  Cornell  University ,  New  York. 
"It  is  far  and  away  the  best  that  has  come  to  my  notice,  and  I  shall  take  great  pleasure  in 
recommending  it  to  my  nurses,  and  students  as  well." 


i6      SAUNDERS'  BOOKS  ON  GYNECOLOGY  AND   OBSTETRICS. 

American  Pocket  Dictionary  ^^^  ^^"^'^^  ^'*^*^°" 

The  American  Pocket  Medical  Dictionary.  Edited  by  W. 
A.  Newman  Borland,  A.M.,  M.  D.,  Assistant  Obstetrician  to  the 
Hospital  of  the  University  of  Pennsylvania;  Fellow  of  the  American 
Academy  of  Medicine.  Over  598  pages.  Full  leather,  hmp,  with 
gold  edges.     |i.oo  net;  with  patent  thumb  index,  $1.2^  net. 

James  W.  Holland.  M.  D., 

Professor   of  Medical    Chemistry    and    Toxicology    at  the  Jeffersoti    Aledical    College^ 
Philadelphia. 

"  I  am  struck  at  once  with  admiration  at  the  compact  size  and  attractive  exterior.  I 
can  recommend  it  to  our  students  without  reserve." 

Cra^in*S    GyneCOlOg(y.  New  (6th)  Edition 

Essentials  of  Gynecology.  By  Edwin  B.  Cragin,  M.  D., 
Professor  of  Obstetrics,  College  of  Physicians  and  Surgeons,  New 
York.  Crown  octavo,  215  pages,  62  illustrations.  Cloth,  ^i.oo 
net.     In  Saunders'   Question- Compend  SejHes. 

The  Medical  Record,  New  York 

"A  handy  volume  and  a  distinct  improvement  of  students'  compends  in  general. 
No  author  who  was  not  himself  a  practical  gynecologist  could  have  consulted  the 
student's  needs  so  thoroughly  as  Dr.  Cragin  has  done." 

Ashton's    Obstetrics.  New  (6th)  Edition 

Essentials  of  Obstetrics.  By  W.  Easterly  Ashton,  M.D., 
Professor  of  Gynecology  in  the  Medico-Chirurgical  College,  Phila- 
delphia. Crown  octavo,  256  pages,  75  illustrations.  Cloth,  ^i.oo 
net.     In  Saunders'  Question- Compend  Series. 

Southern  Practitioner 

"  An  excellent  little  volume  containing  correct  and  practical  knowledge.  An  admir- 
able compend,  and  the  best  condensation  we  have  seen." 

Barton  and  Wells*  Medical  Thesaurus 

A  Thesaurus  of  Medical  Words  and  Phrases.  By  Wilfred 
M.  Barton,  M.  D.,  Assistant  to  Professor  of  Materia  Medica  and 
Therapeutics,  Georgetown  University,  Washington,  D.  C. ;  and 
Walter  A.  Wells,  M.  D.,  Demonstrator  of  Laryngology,  George- 
town University,  Washington,  D.  C.  i2mo  of  534  pages.  Flex- 
ible leather,  ;^2.50  net;  with  thumb  index,  ;^3.oo  net. 

Macfarlane's   Gynecology  for  Nurses 

A  Reference  Hand-Book  of  Gynecology  for  Nurses.  By  Cath- 
arine Macfarlane,  M.  D.,  Gynecologist  to  the  Woman's  Hospital  of 
Philadelphia.  32010  of  150  pages,  with  70  illustrations.  Flexible 
leather,  $1.25  net. 

A.  M.  Seabrook,  M.  D., 

Woman's  Medical  College  of  Philadelphia. 

"  It  is  a  most  admirable  little  book,  covering  in  a  concise  but  attractive  way  the  subject 
from  the  nurse's  standpoint." 


